Racial and Ethnic Health Disparities in Delay to Initiation of Intensity-Modulated Radiotherapy

Abstract

PURPOSE: Delays in initiation of radiotherapy may contribute to inferior oncologic outcomes that are more commonly observed in minoritized populations in the United States. We aimed to examine inequities associated with delayed initiation of intensity-modulated radiotherapy (IMRT). MATERIALS AND METHODS: The National Cancer Database was queried to identify the 10 cancer sites most commonly treated with IMRT. Interval to initiation of treatment (IIT) was broken into quartiles for each disease site, with the 4th quartile classified as delayed. Multivariable logistic regression for delayed IIT was performed for each disease site using clinical and demographic covariates. Differences in magnitude of delay between subsets of patients stratified by race and insurance status were evaluated using two-sample t-tests. RESULTS: Among patients (n = 350,425) treated with IMRT between 2004 and 2017, non-Hispanic Black (NHB), Hispanic, and Asian patients were significantly more likely to have delayed IIT with IMRT for nearly all disease sites compared with non-Hispanic White (NHW) patients. NHB, Hispanic, and Asian patients had significantly longer median IIT than NHW patients (NHB 87 days, P < .01; Hispanic 76 days, P < .01; Asian 74 days, P < .01; and NHW 67 days). NHW, Hispanic, and Asian patients with private insurance had shorter median IIT than those with Medicare ( P < .01); however, NHB patients with private insurance had longer IIT than those with Medicare ( P < .01). CONCLUSION: Delays in initiation of IMRT in NHB, Hispanic, and Asian patients may contribute to the known differences in cancer outcomes and warrant further investigation, particularly to further clarify the role of different insurance policies in delays in advanced modality radiotherapy.

Differential impact of missed initial wound clinic visit on 6‐month wound healing by race/ethnicity among patients with chronic limb‐threatening ischemia

“…Similarly poor results are seen in diabetes and cancer diagnosis, care, and outcomes, among other diseases, for Hispanic/Latino individuals, American Indians/Alaskan Natives, and Asian Americans 25–29 . Adjusting for delays in care attenuates but does not eliminate these relationships, suggesting that the longer time it takes to initiate care only partially explains poor outcomes among minority patients 18–21 . Our results show that the combination of non‐White race/ethnicity and missed first visit is associated with a very low proportion of wound healing.…”

“…[25][26][27][28][29] Adjusting for delays in care attenuates but does not eliminate these relationships, suggesting that the longer time it takes to initiate care only partially explains poor outcomes among minority patients. [18][19][20][21] Our results show that the combination of non-White race/ethnicity and missed first visit is associated with a very low proportion of wound healing. However, patients who completed their wound care initiation visit as scheduled had similar outcomes regardless of race, indicating that efforts to successfully initiate wound care among non-White patients may result in improved wound healing.…”

“…Though not previously studied in patients with CLTI, the interrelatedness of racial disparities, initiation of care, and adverse health outcomes has been demonstrated in other clinical contexts. For example, compared with White patients, Black and other non‐White patients have significantly delayed care for initiation of dialysis, chemotherapy/radiation, and prenatal care, among other types of care 18–21 . Independent of initiation of care, these same Black patients are also 4 times more likely to develop kidney failure, present with more advanced stages of breast, lung, and colon cancer with lower 5‐year survival rates, and experience increased rates of pregnancy‐related maternal complications and death when compared to their White/non‐Hispanic counterparts 22–24 .…”

Disparities in Access to Radiotherapy Among Hispanic/Latinx Populations in the United States

“…We identified 12 articles addressing disparities in time to initiate treatment, and complete treatment. Of the 12 articles identified, 10 had findings that indicate the existence of a disparity for the Hispanic population in this area, [11][12][13][14][15][16][17][18][19][20] whereas 2 did not. 30,38 Studies identified a longer time from presentation to first RT treatment for those with Hispanic ethnicity compared with Non-Hispanic patients.…”

“…They demonstrated that Hispanic patients, among other minority groups, were significantly more likely to have delayed initiation of treatment for nearly all disease sites compared with NHW patients, with Hispanic patients having a median time to treatment initiation of 76 days compared with a median time of 67 days for NHW patients (P < 0.01). 16 In addition to greater time to initiate treatment, it was also identified that Hispanic patients had greater amounts of time to complete RT. 19,20 Lamm and colleagues conducted a retrospective study on patients undergoing breast conservation therapy for early-stage breast cancer, evaluating the timely completion of adjuvant radiation with hypofractionated and conventional regimens.…”