‘Striking’ racial disparities observed in surgical care of gastrointestinal tract cancer
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Black patients with gastrointestinal tract cancer had a higher likelihood than their white counterparts of receiving surgical and adjuvant treatment that deviates from the standard of care, according to a study published in JAMA Network Open.
“Racial and ethnic disparities have been reported in the United States health care system, and the COVID-19 pandemic has brought to light these previously reported disparities. Gastrointestinal cancer accounts for approximately one-third of all cancer deaths,” Baylee F. Bakkila, BA, BS, and Sajid A. Khan, MD, FACS, of Yale School of Medicine, and Caroline H. Johnson, PhD, of Yale School of Public Health, told Healio | HemOnc Today in a joint statement. “Given our team’s expertise at Yale in gastrointestinal surgical oncology, we wanted to examine whether race-specific treatment disparities exist with curative-intent surgery and the impact this might have on clinical outcome for patients across the U.S.”
The retrospective cohort study included 565,124 adults (10.9% Black, 83.5% white; 54.7% men; 50.7% with Medicare coverage) diagnosed with gastrointestinal tract cancers between 2004 to 2017 who underwent surgical resection. Researchers defined oncologic standard of care as negative resection margin, adequate lymphadenectomy and receipt of adjuvant chemotherapy and/or radiotherapy as indicated.
Results showed associations of longer median survival with negative resection margins (87.3 months vs. 22.9 months; P < .001) and adequate lymphadenectomies (80.7 months vs. 57.6 months; P < .001).
Researchers reported that, after adjustment for covariates, Black patients had a lower likelihood of negative surgical margins than white patients overall (OR = 0.96; 95% CI, 0.93-0.98) and after esophagectomy (OR = 0.71; 95% CI, 0.58-0.87), proctectomy (OR = 0.71; 95% CI, 0.66-0.76) and biliary resection (OR = 0.75; 95% CI, 0.61-0.91).
Black patients also appeared less likely to have adequate lymphadenectomy overall (OR = 0.89; 95% CI, 0.87-0.91) and specifically after colectomy (OR = 0.89; 95% CI, 0.87-0.92), esophagectomy (OR = 0.72; 95% CI, 0.63-0.83), pancreatectomy (OR = 0.9; 95% CI, 0.85-0.96), proctectomy (OR = 0.93; 95% CI, 0.88-0.98), proctocolectomy (OR = 0.9; 95% CI, 0.81-1) and enterectomy (OR = 0.71; 95% CI, 0.65-0.79).
In addition, compared with white patients, Black patients had higher odds of not being recommended for chemotherapy (OR = 1.15; 95% CI, 1.1-1.21) and radiotherapy (OR = 1.49; 95% CI, 1.35-1.64) because of comorbidities, and lower odds of receiving recommended chemotherapy (OR = 1.68; 95% CI, 1.55-1.82) and radiotherapy (OR = 2.18; 95% CI, 1.97-2.41) for unknown reasons.
Additionally, researchers noted American Indian patients demonstrated a 11% lower likelihood of negative resection margins and 23% lower likelihood of adequate lymph node removal compared with white patients.
The extent of the disparities in recommended postoperative chemotherapy and radiation therapy surprised Yale researchers, they said.
“Even though Black and white patients were equally likely to refuse postoperative chemotherapy and radiation therapy, suggesting that patient decision-making largely does not differ by race, it is striking that Black patients were less likely to be treated by physicians with both of these postoperative therapies,” Bakkila, Khan and Johnson said in the statement. “Research into potential biases by physicians and the health care system should be explored.”
The researchers told Healio | HemOnc Today they planned to explore the national cohort data further, at the hospital level, to better understand the socioeconomic components of race-specific treatment disparities. Additionally, they are exploring whether factors that contribute to disparities in gastrointestinal surgical oncology treatment exist, such as access to cancer screening, lifestyle, diet, tobacco use, access to transportation to medical centers, access to medical providers and education status.
“We are [also] examining for biases among clinicians and discrepancies in surgical and pathology equipment at treatment centers that primarily serve under-resourced communities,” they said in the statement.
In a related editorial, Shervin Assari, MD, MPH, associate professor of family medicine at Charles R. Drew University of Medicine and Science, and Helena Hansen, MD, PhD, chair of research theme in translational social science and health equity and associate director of the Center for Social Medicine at UCLA’s David Geffen School of Medicine, wrote the Yale study leaves questions about the systemic mechanisms driving inequalities unanswered.
“The time has come to address the root causes of inequalities in the U.S. health care system and society at large that act at a systemic level,” Assari and Hansen wrote. “It is only through such concerted movement toward systemic change that we can eliminate racial and ethnic inequalities in health and health care.”
- References:
- Assari S, et al. JAMA Netw Open. 2022;doi:10.1001/jamanetworkopen.2022.5676.
- Bakkila BF, et al. JAMA Netw Open. 2022;doi:10.1001/jamanetworkopen.2022.5664.
- For more information:
- Baylee F. Bakkila, BA, BS, can be reached at Yale School of Medicine, P.O. Box 208062, New Haven, CT 06520-8062; email: baylee.bakkila@yale.edu.
- Caroline H. Johnson, PhD, can be reached at Department of Environmental Health Sciences, Yale School of Public Health, Yale University, 60 College St., New Haven, CT 06510; email: caroline.johnson@yale.edu.
- Sajid A. Khan, MD, FACS, can be reached at Division of Surgical Oncology, Department of Surgery, Yale School of Medicine, P.O. Box 208062, New Haven, CT 06520-8062; email: sajid.khan@yale.edu.
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