Demographic disparities in delay of definitive chemoradiation for anal squamous cell carcinoma: a nationwide analysis

Abstract

Background: Prolonged time to treatment initiation (TTI) for patients with curable anal cancer may reduce tumor control. This study investigated demographic disparities in TTI for patients receiving definitive chemoradiation (CRT) for anal squamous cell carcinoma (A-SCC). Methods: Adult patients with A-SCC diagnosed from 2004 to 2014 and treated with definitive CRT were identified in the National Cancer Database (NCDB). TTI was defined as days from diagnosis to start of CRT. A negative binomial regression model estimated predicted TTI (pTTI) values. Cox proportional hazards model evaluated the impact of TTI on overall survival (OS). Results: Overall, 12,546 patients were included with 9% Non-Hispanic Black patients and 4% Hispanic patients. Multivariable analysis (MVA) showed that pTTI varied significantly by race/ethnicity with Non-Hispanic Black patients having a pTTI of 50 vs. 38 days for Non-Hispanic White patients [relative risk (RR), 1.21; 95% confidence interval (CI), 1.17-1.25]. For Hispanic patients, pTTI was 48 days, significantly longer than that of Non-Hispanic White patients (RR, 1.19; 95% CI, 1.14-1.24). Gender, insurance status, education level, urban category, distance to reporting facility, treatment facility type, intensity-modulated radiation therapy (IMRT)/proton use, T/N classification, and comorbidity status were all also associated with significant variation in TTI. TTI was not independently associated with changes in OS on MVA [hazard ratio (HR), 0.999; 95% CI, 0.997-1.002]. Conclusions: Non-Hispanic Black and Hispanic patients have longer delays in starting definitive CRT for A-SCC. While TTI was not associated with OS, future analyses should explore the impact of TTI on local control, metastases, and patient-reported outcomes.

Socioeconomic disparities in timeliness of care and outcomes for anal cancer patients

“…Timeliness of care is widely recognized as an important health care quality metric . ASCC patients who are Black, publicly insured, or living in areas with lower education have been shown to experience greater treatment initiation delays . In this study, median time from diagnosis to treatment initiation for the entire cohort was 7.9 weeks, with unpartnered and Medicaid patients suffering longer delays.…”

“…27 ASCC patients who are Black, publicly insured, or living in areas with lower education have been shown to experience greater treatment initiation delays. 10 In this study, median time from diagnosis to treatment initiation for the entire cohort was 7.9 weeks, with unpartnered and Medicaid patients suffering longer delays. This is consistent with research in other cancers, in which married patients have been found to present to care at earlier stages and to have improved survival.…”

“…Diagnostic and treatment initiation delays have been studied as potential mediators of socioeconomic disparities in cancer outcomes. Patients who are Black, publicly insured, or living in areas with lower education have been shown to suffer longer treatment delays in ASCC . Treatment delays have been associated with decreased survival in multiple cancers .…”

“…Patients who are Black, publicly insured, or living in areas with lower education have been shown to suffer longer treatment delays in ASCC. 10 Treatment delays have been associated with decreased survival in multiple cancers. [11][12][13] In addition, low SES patients have been found to present to care at more advanced stages of ASCC and other cancers, often with adverse effects on survival.…”

Racial disparities in receipt of standard chemoradiation in anal squamous cell carcinoma, an analysis of the National Cancer Database

“…The authors hypothesized that this racial disparity could be due to an interplay of structural, cultural, and social barriers to healthcare as well as tumor biology. On the contrary, two more recent NCDB studies, one from 2004 to 2013 and one from 2004 to 2014 both did not find evidence of racial disparities in survival on multivariable analysis 22,24 …”