Racial Disparities in Surgical Resection and Survival among Elderly Patients with Poor Prognosis Cancer

Abstract

Background Reports indicate that blacks have lower survival following the diagnosis of a poor prognosis cancer, compared with whites. We explored the extent to which this disparity is attributable to the underuse of surgery. Study Design Using the SEER-Medicare database we identified 57,364 patients, ages ≥65, with a new diagnosis of non-metastatic liver, lung, pancreatic and esophageal cancer, from 2000-2005. We evaluated racial differences in resection rates after adjustment for patient, tumor and hospital characteristics, using hierarchical logistic regression. Cox proportional hazards regression was used to assess racial differences in survival, after adjusting for patient, tumor and hospital characteristics, and receipt of surgery. Results Compared with whites, blacks were less likely to undergo surgery for liver (adjusted OR [aOR], 0.49, 95%CI 0.29-0.83), lung (aOR 0.62 95%CI 0.56-0.69), pancreas (aOR 0.53, 95%CI 0.41-0.70) and esophagus cancers (aOR 0.64, 95%CI 0.42-0.99). Hospitals varied in their surgery rates among patients with potentially resectable disease. However, resection rates were consistently lower for blacks, regardless of the resection rate of the treating hospital. Although there were no racial differences in overall survival with liver and esophageal cancer, blacks experienced poorer survival for lung (adjusted HR [aHR]1.05, 95%CI 1.00-1.10) and pancreas cancer (aHR 1.15, 95%CI 1.03-1.30). In both instances, there were no residual racial disparities in overall survival after further adjusting for use of surgery. Conclusions Blacks are less likely to undergo surgery following the diagnosis of a poor prognosis cancer. Our findings suggest that surgery is an important predictor of overall mortality, and that efforts to reduce racial disparities will require stakeholders to gain a better understanding of why elderly blacks are less likely to get to the operating room.

Race Does Not Impact Pancreatic Cancer Treatment and Survival in an Equal Access Federal Health Care System

“…Using SEER-Medicare data from 2000 to 2007, Revels et al reported that only 29 % of patients underwent surgery surgical resection for locoregional pancreatic cancer. 4 Similarly, using data from the National Cancer Data Base from 1995 to 2004, Bilimoria et al 15 found that even among patients with stage I pancreatic cancer, only 26.8 % underwent resection. After excluding patients with severe medical comorbidities and patients who refused surgery, 52 % of patients with stage I disease still did not undergo resection.…”

“…Previous studies based on large national databases have demonstrated that black patients in the general population are less likely to undergo surgical resection and less likely to receive adjuvant therapy for locoregional PDAC than white patients. [2][3][4][5][6]9,15 Murphy et al demonstrated that black patients with locoregional pancreatic cancer are less likely to see a medical oncologist, radiation oncologist, and surgeon, and are less likely to receive surgery and chemotherapy. 6 We did not observe these treatment disparities among patients treated in the DoD health care system.…”

“…The absence of this disparity can likely be attributed to the absence of variability in rates of utilization of surgical resection, adjuvant therapy, and palliative treatments. Indeed, multiple studies have demonstrated that, after adjusting for surgical resection, black [2][3][4] Other factors may lead to disparities in the receipt of surgical and nonsurgical therapies among patients with pancreatic cancer. These include patients' personal beliefs, fear, culture, and the patient-doctor relationship.…”

“…Disparities in the outcome of pancreatic adenocarcinoma (PDAC) have been observed among black patients, who face decreased overall survival duration compared to white patients. [2][3][4][5][6][7][8] As previous studies have demonstrated that black patients with PDAC undergo surgical evaluation, surgical resection, and adjuvant therapy less frequently than white patients, it is possible that differences in pancreatic cancer outcomes observed between races may be the result of differences in access to quality health care. 2,3,5,6,9 Because racial and ethnic minorities are less likely to have health insurance, some have suggested universal health care coverage might help reduce this health care disparity.…”

Does Quality of Care Matter? A Study of Adherence to National Comprehensive Cancer Network Guidelines for Patients with Locally Advanced Esophageal Cancer

“…18 More recently, Revels et al reported that elderly black patients are less likely to undergo surgery after diagnosis of several poor prognosis cancers, including esophageal cancer, regardless of the resection rate of the treating hospital. 19 Reasons for this disparity are still not fully understood, yet it should not be forgotten that surgery remains the mainstay for treatment of esophageal cancer and can drastically modify the natural history of the disease. Therefore, efforts should be made to individuate and remove obstacles towards equal access to the best treatment across races.…”