Racial inequity and other social disparities in the diagnosis and management of bladder cancer

BACKGROUND

We investigate the impact of gender, race, and socioeconomic status on the diagnosis and management of bladder cancer in the United States.

METHODS

We utilized the National Cancer Database to stratify cases of urothelial cell carcinoma of the bladder as early (Tis, Ta, T1), muscle invasive (T2-T3, N0), locally advanced (T4, N1-3), and metastatic. Multivariate binomial and multinomial logistic regression analyses identified demographic characteristics associated with stage at diagnosis and receipt of cancer-directed therapies. Odds ratios (OR) are reported with 95% confidence intervals.

RESULTS

After exclusions, we identified 331,714 early, 72,154 muscle invasive, 15,579 locally advanced, and 15,161 metastatic cases from 2004-2016. Relative to diagnosis at early stage, the strongest independent predictors of diagnosis at muscle invasive, locally advanced, and metastatic disease included Black race (OR = 1.19 [1.15-1.23], OR = 1.49 [1.40-1.59], OR = 1.66 [1.56-1.76], respectively), female gender (OR = 1.21 [1.18-1.21], OR = 1.16 [1.12-1.20], and OR = 1.34 [1.29-1.38], respectively), and uninsured status (OR = 1.22 [1.15-1.29], OR = 2.09 [1.94-2.25], OR = 2.57 [2.39-2.75], respectively). Additional demographic factors associated with delayed diagnosis included older age, treatment at an academic center, Medicaid insurance and patients from lower income/less educated/more rural areas (all p < 0.01). Treatment at a non-academic center, older age, women, Hispanic and Black patients, lower income and rural areas were all less likely to receive cancer-directed therapies in early stage disease (all p < 0.01). Women, older patients, and Black patients remained less likely to receive treatment in muscle invasive, locally advanced, and metastatic disease (all p < 0.01).

CONCLUSION

Black race was the strongest independent predictor of delayed diagnosis and substandard treatment of bladder cancer.

Socioeconomic disparities in colorectal cancer survival: contributions of prognostic factors in a large Australian cohort

Purpose

We quantified the contributions of prognostic factors to socioeconomic disparities in colorectal cancer survival in a large Australian cohort.

Methods

The sample comprised 45 and Up Study participants (recruited 2006–2009) who were subsequently diagnosed with colorectal cancer. Both individual (education attained) and neighbourhood socioeconomic measures were used. Questionnaire responses were linked with cancer registrations (to December 2013), records for hospital inpatient stays, emergency department presentations, death information (to December 2015), and Medicare and Pharmaceutical Benefits claims for subsidised procedures and medicines. Proportions of socioeconomic survival differences explained by prognostic factors were quantified using multiple Cox proportional hazards regression.

Results

1720 eligible participants were diagnosed with colorectal cancer after recruitment: 1174 colon and 546 rectal cancers. Significant colon cancer survival differences were only observed for neighbourhood socioeconomic measure (p = 0.033): HR = 1.55; 95% CI 1.09–2.19 for lowest versus highest quartile, and disease-related factors explained 95% of this difference. For rectal cancer, patient- and disease-related factors were the main drivers of neighbourhood survival differences (28–36%), while these factors and treatment-related factors explained 24–41% of individual socioeconomic differences. However, differences remained significant for rectal cancer after adjusting for all these factors.

Conclusion

In this large contemporary Australian cohort, we identified several drivers of socioeconomic disparities in colorectal cancer survival. Understanding of the role these contributors play remains incomplete, but these findings suggest that improving access to optimal care may significantly reduce these survival disparities.

Racial and Socioeconomic Disparities in Breast Cancer Outcomes within the AJCC Pathologic Prognostic Staging System

BACKGROUND

Non-Hispanic black (NHB) women and those of lower socioeconomic status (SES) have inferior breast cancer outcomes compared with non-Hispanic white (NHW) women and those of higher SES. We examined racial and SES disparities in breast cancer survival within the AJCC 8th edition pathologic prognostic staging system.

METHODS

Using the Surveillance, Epidemiology and End Results Program, we identified patients diagnosed with invasive breast cancer from 2010 to 2015, with follow-up through 2016. Census tract-level SES (cSES) data were available as a composite index and analyzed in quintiles. Cox proportional-hazards survival analyses adjusted for age, race, cSES, insurance, marital status, histology, pathologic prognostic stage, and treatment were used to estimate disease-specific survival (DSS).

RESULTS

A total of 259,852 patients were included: 176,369 (67.9%) NHW; 28,510 (11.0%) NHB; 29,737 (11.4%) Hispanic; and 22,887 (8.8%) Asian. NHB race and lower cSES were associated with increased incidence of triple-negative disease compared with NHW (p < 0.01). NHB race, lower cSES, public insurance, lower education, and increased poverty were associated with lower DSS. Survival analyses adjusting for cSES, tumor, and treatment characteristics demonstrated that NHB patients had inferior DSS within each AJCC pathologic prognostic stage (hazard ratio [HR] 1.25, 95% confidence interval [CI] 1.20-1.30) compared with NHW patients. Fully adjusted models also showed patients residing in lower SES counties had inferior DSS.

CONCLUSIONS

Racial and cSES disparities in breast cancer-specific mortality were evident across all stages, even within the pathologic prognostic staging system which incorporates tumor biology. Future efforts should assess the biological, behavioral, social, and environmental determinants that underlie racial and SES inequities in outcomes.

Factors Associated With Receipt of Partial Nephrectomy or Minimally Invasive Surgery for Patients With Clinical T1a and T1b Renal Masses: Implications for Regionalization of Care

PURPOSE

To identify factors associated with receipt of partial nephrectomy (PN) and minimally invasive surgery (MIS) in patients with clinical T1 renal cell carcinoma (RCC) using the National Cancer Data Base (NCDB).

METHODS

We queried the NCDB from 2010 to 2014 identifying patients treated surgically for cT1a-bN0M0 RCC. Logistic regression was used to examine associations between socioeconomic, clinical, and treatment factors, and receipt of MIS or PN within the T1 patient population.

RESULTS

Our cohort included 69,694 patients (cT1a, n = 44,043; cT1b, n = 25,651). For cT1a tumors, 70% of patients received PN and 65% underwent MIS. For cT1b tumors, 32% of patients received PN and 62% underwent MIS. cT1a and cT1b patients with household income < $62,000, without private insurance, and treated outside academic centers were less likely to receive MIS or PN. cT1a patients traveling > 31 miles were more likely to undergo MIS. For both cT1a/b, the farther a patient traveled for treatment, the more likely a PN was performed.

CONCLUSION

Data showed an increase in utilization of MIS and PN from 2010 to 2014. However, patients in the lowest socioeconomic groups were less likely to travel and were more likely to receive more invasive treatments. On the basis of these findings, additional research is needed into how regionalization of RCC surgery affects treatment disparities.

Socioeconomic status and survival outcomes in elderly cancer patients: A national health insurance service-elderly sample cohort study

BACKGROUND

We hypothesized that lower socioeconomic status (SES) was associated with higher all-cause mortality in patients newly diagnosed with cancer, particularly in the elderly population.

METHODS

We collected study patients from the stratified random sample of Korean National Health Insurance Elderly Cohort (2002-2015). The Cox's proportional hazards model was used to investigate the risk factors for mortality. Income level and composite deprivation index (CDI) 2010 were used to define the SES: low, intermediate, and high SES groups. The comorbidities were measured using Charlson Comorbidity Index score. After a wash-out period (2002), the final study population was 108 626 (2003-2015).

RESULTS

In multivariate analysis, low SES was associated with poor overall survival (OS) (HR = 1.08, 95% CI: 1.05-1.12, P < 0.001) and cancer-specific survival (CSS) (HR = 1.11, 95% CI: 1.06-1.16, P < 0.001) particularly for patients aged 70-79 years. High SES was favorable prognostic factor of OS in patients aged 60-69 years (HR = 0.85, 95% CI: 0.81-0.89, P < 0.001), 70-79 years (HR = 0.90, 95% CI: 0.87-0.93, P < 0.001), and ≥80 years (HR = 0.91, 95% CI: 0.87-0.96, P < 0.001). However, SES was not associated with CSS in advanced age patients (≥80 years). Patients with low SES manifesting colorectal, urinary, liver, gastric, melanoma, and esophageal cancers demonstrated worse OS, compared to patients with intermediate SES. Also, low SES patients with urinary, liver, or colorectal cancers or melanoma demonstrated worse CSS compared to those with intermediate SES.

CONCLUSION

Low SES at the time of cancer diagnosis is associated with increased risk of OS and CSS in elderly patients. Depending on cancer sites, different patterns of OS and CSS were observed according to SES. Further elucidation of the causes underlying these phenomena is needed along with appropriate support for elderly cancer patients with low SES.

Facility Variation in Local Staging of Rectal Adenocarcinoma and its Contribution to Underutilization of Neoadjuvant Therapy

BACKGROUND

Guidelines recommend neoadjuvant therapy (NT) for clinical stage II-III (locally advanced) rectal adenocarcinoma, but utilization remains suboptimal. The causes of NT omission remain poorly understood.

METHODS

The main outcomes in this study of patients with resected clinically non-metastatic rectal adenocarcinoma in the 2010-2015 National Cancer Database were local staging utilization in patients with non-metastatic tumors (i.e., undocumented clinical stage/pathologic stage I-III) and NT utilization for locally advanced tumors. Multivariable regression was used to examine predictors of these outcomes. Facility-specific risk- and reliability-adjusted local staging and NT rates were calculated. Positive margins and overall survival (OS) were examined as secondary outcomes.

RESULTS

Local staging was omitted in 7737/43,819 (17.7%) patients with clinically non-metastatic tumors and NT was omitted in 5199/31,632 (16.4%) patients with locally advanced tumors. NT was utilized in 24,826 (91.1%) locally advanced patients who had local staging vs. 1607 (36.6%) patients who did not; 2785 (53.6%) locally advanced patients with NT omitted also had local staging omitted. Treatment at facilities with lowest quintile local staging rates was associated with NT omission (relative risk 2.41, 95% confidence interval 2.11, 2.75). Adjusted facility local staging rates varied sixfold (16.1-98.0%), facility NT rates varied twofold (43.9-95.9%), and they were correlated (r = 0.58; P < 0.001). Local staging omission and NT omission were independently associated with positive margins and decreased OS.

CONCLUSIONS

Local staging omission is a common care process in over half of cases of omitted NT. These data emphasize the need for quality improvement efforts directed at providing facilities feedback about their local staging rates.

Disparities in utilization of treatment for clinical stage I-II pancreatic adenocarcinoma by area socioeconomic status and race/ethnicity

BACKGROUND

Utilization of multimodality therapy for clinical stage I-II pancreatic ductal adenocarcinoma is associated with meaningful prolongation of survival. Although the qualitative existence of disparities in treatment utilization by socioeconomic status and race/ethnicity is well documented, the absolute magnitudes of these disparities have not been previously quantified.

METHODS

The exposures in this retrospective cohort study of the 2010-2015 National Cancer Database were a 7-value area-level socioeconomic status index and race/ethnicity. Main outcomes were surgery, chemotherapy, and multimodality therapy (surgery and chemotherapy). Adjusted rate differences were calculated after logistic regression. Models excluded intermediate variables. Overall survival was evaluated in unadjusted and adjusted analyses.

RESULTS

Of 43,760 patients, 63.4% underwent surgery. Of 39,808 patients without chemotherapy contraindications, refusal, or missing data, 75.1% received chemotherapy and 51.4% received multimodality therapy. Adjusted rate differences for utilization of surgery, chemotherapy, and multimodality therapy in the lowest socioeconomic status patients were -10.0 (95% confidence interval [CI] -12.4 to -7.5), -12.7 (95% CI -16.3 to -9.1), and -15.4 (95% CI -18.8 to -12.0), respectively, versus the highest socioeconomic status patients. Adjusted rate differences for multimodality therapy utilization in non-Hispanic Black and Hispanic patients were -10.1 (95% CI -13.6 to -6.7) and -11.8 (95% CI -14.3 to -9.2), respectively, versus non-Hispanic White patients. Median overall survival increased in a graded fashion from 14.1 (95% CI 13.4-14.8) months in the lowest socioeconomic status patients to 20.2 months (95% CI 19.6-20.8) in the highest socioeconomic status patients. Survival differences were attenuated but not eliminated in multivariable Cox models.

CONCLUSION

Socioeconomic status and race/ethnicity are more powerful determinants of whether patients receive treatment for clinical stage I-II pancreatic ductal adenocarcinoma than previously appreciated. Nationwide quality improvement efforts aimed at addressing these inequities are warranted.