As proton beam therapy use for cancer increased, ‘so did the racial disparity in receipt’
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Use of proton beam therapy increased significantly among patients with cancer in the U.S. between 2004 and 2018, but Black individuals had a lower likelihood of receiving the therapy than their white counterparts.
Researchers presented the findings of two cross-sectional studies in JAMA Network Open.
Rationale and methods
“Proton beam therapy can deliver a higher dose of radiation to the tumor with less damage to surrounding healthy cells,” Leticia M. Nogueira, PhD, MPH, senior principal scientist in the surveillance and health services research program at American Cancer Society, told Healio. “Therefore, proton beam therapy is potentially superior to photon-based radiation therapy to treat tumors with complex anatomy, surrounded by sensitive tissues, or for treating childhood cancer, where long-term side effects of radiation therapy are a main concern. However, proton beam therapy can cost twice as much as photon-based radiation therapy.”
In the first study, Nogueira and colleagues examined the overall patterns of use of proton beam therapy according to the American Society for Radiation Oncology’s U.S. clinical indications. Researchers divided patients into two groups: Group one included those for whom proton beam therapy is recommended and group two included those for whom evidence of proton beam therapy efficacy is still under review.
In the second study, researchers assessed whether racial disparities exist in the receipt of proton beam therapy between Black and white individuals. The cross-sectional study included 5,225,929 patients (mean age, 63.2 years; 86.4% white and 13.6% Black; 54.3% women) included in the National Cancer Database eligible to undergo proton beam therapy for various cancer types between 2004 and 2018.
Researchers used propensity score matching to ensure comparability of Black and white patients’ clinical characteristics and regional availability of proton beam therapy per the National Academy of Medicine’s definition of disparities.
Key findings
Results of the first study showed use of proton beam therapy in the U.S. increased overall for all new cancer diagnoses — from 0.4% in 2004 to 1.2% in 2018 (annual percent change [APC], 8.12; P < .001).
Researchers reported significant increases (P < .001) in group one from 2010 to 2018 (0.4% to 2.2%; APC = 21.97) and in group two from 2014 to 2018 (0.03% to 0.1%; APC = 30.57). In group two, they observed the largest increases between 2010 and 2018 in proton beam therapy targeted to the breast (0% to 0.9%; APC = 51.95) and to the lung (0.1% to 0.7%; APC = 28.06; P < .001 for both). The only decrease in use occurred in prostate cancer between 2011 and 2014 (1.4% to 0.8%; APC = 16.48; P = .03); however, use for this cancer site rebounded to 1.3% in 2018 (APC = 12.45; P < .001).
The second study revealed Black patients had a lower likelihood than white patients of receiving proton beam therapy (0.3% vs. 0.5%; OR = 0.67; 95% CI, 0.64-0.71).
In addition, researchers observed increased racial disparities among those included in group one (0.4% vs. 0.8%; OR = 0.49; 95% CI, 0.44-0.55) compared with those in group two (0.3% vs. 0.4%; OR = 0.75; 95% CI, 0.7-0.8). The disparities observed among group one patients increased throughout time (APC = 0.09; P < .001), with the greatest increase observed in 2018.
Researchers also found patients in group one most likely to have private health insurance (55.4%) during 2018, whereas most of those in group two had Medicare (52.5%).
“Of note, the racial disparity in receipt of proton beam therapy was greatest for the two most common U.S. childhood cancers — rhabdomyosarcoma and central nervous system cancers. Matching on socioeconomic status or health insurance coverage type did not eliminate these disparities,” Nogueira said. “As the number of facilities offering proton beam therapy in the U.S. increased, so did the racial disparity in receipt of proton beam therapy. Therefore, increasing availability of therapeutic advances without addressing structural determinants of racial disparities can worsen, instead of ameliorating, racial disparities in receipt of quality cancer treatment.”
Implications
Black individuals continue to have worse access to quality cancer care in the U.S., and modifiable factors, other than availability of new therapeutic options, need to be addressed to eliminate racial disparities in cancer care and outcomes, Nogueira said.
“Future research should evaluate the contribution of oncology referral patterns, provider intrinsic bias and institutions’ policies and practices, such as provision of transportation services and clinical trial enrollment practices, to racial disparities in receipt of quality cancer care,” she added.
References:
Nogueira LM, et al. JAMA Netw Open. 2022;doi:10.1001/jamanetworkopen.2022.8970.
Nogueira LM, et al. JAMA Netw Open. 2022;doi:10.1001/jamanetworkopen.2022.9025.
For more information:
Leticia M. Nogueira, PhD, MPH, can be reached at American Cancer Society, 250 Williams St., Atlanta, GA 30067; email: leticia.nogueira@cancer.org.
Perspective
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Isabelle Choi, MD
The two studies published in JAMA Network Open contained both positive and distressing news about the use of proton radiation therapy as an effective modality to treat a range of cancers.
On the positive side, the first of these studies showed a rise in the use of proton therapy to treat complex tumors in patients with a range of malignancies. Given proton therapy has proven a highly effective and — in some instances — superior modality to traditional photon radiation for improving health outcomes, this is a development we should celebrate.
The second of these studies, however, revealed evidence of persistent racial disparities in access to proton therapy, which remains more expensive than traditional radiation and is less commonly covered by health insurance. This finding reflects racial inequities that exist across our health care system more broadly.
At the New York Proton Center (NYPC), we recognize that proton therapy is not as widely available to patients — particularly Black patients, as the JAMA Network Open research showed—as it should be. We are committed to increasing access, and we work on an individualized basis with each of our patients to ensure a financially feasible path to treatment.
Based in New York City, we treat a more diverse population than most proton centers, and we serve the highest percentages of patients enrolled in Medicaid of any center. Every day we see the barriers patients face in accessing the care they need.
What can the industry do to break down barriers to access?
First, providers can work with each patient’s insurance company to coordinate the cost of the treatment. Unfortunately, this often involves a time-consuming appeals process. We are proud that we secure approval for 90% of our patients at NYPC with a dedicated finance team to help patients through this process, and we provide additional social support services for people who may not have them in place; currently, many centers cannot offer such services.
Second, we need to continue to build the research base of clinical evidence supporting the efficacy of proton therapy. The team that I lead at NYPC is engaged in a diverse portfolio of innovative clinical trials, including federally funded trials in partnership with dozens of leading cancer centers, aimed at strengthening access to proton therapy for more patients by delivering the rigorous data required by many payers.
Finally, and perhaps most importantly, we need to increase public awareness of proton therapy. There are too many patients for whom proton therapy may be the optimal treatment but who may not even realize it is an available option.
This is an important inflection point in the use of proton therapy. At NYPC, I have seen how we can make this modality work for a diverse patient population. Now is the time to set the entire industry working toward a model that promotes more inclusive access so that patients receive the most effective treatment for their cancer diagnosis.
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