Racial disparities in cancer survival shrink with increased public welfare spending
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Increased state spending on social services such as Medicaid correlated with improved 5-year overall survival among Black adults with cancer, according to study results scheduled for presentation at ASCO Annual Meeting.
Greater state investment in public welfare programs also resulted in a reduction of racial disparities in survival for several cancer types, findings presented during a virtual press briefing Thursday showed.
Background and methods
Previous research has shown associations between cancer outcomes and social determinants of health, which include factors such as financial stability, education, place of residence and insurance status, according to Justin Michael Barnes, MD, MS, of the department of radiation oncology at Washington University School of Medicine in St. Louis.
“Racial disparities in cancer outcomes are likely related to systemic racism that has led to disproportionately adverse conditions regarding the social determinants of health,” Barnes told Healio. “We hypothesized that policies that directly address the social determinants of health, such as public welfare spending, could help overcome the adverse social determinants of health that patients of color with cancer face, and subsequently narrow existing disparities.”
Public welfare includes programs such as Medicaid and Supplemental Security Income that assist individuals who experience socioeconomic challenges.
“Public welfare expenditures comprise about $2,000 per capita per year on average, which is just over 20% of the total state expenditures,” Barnes said during the presentation. “This does vary considerably from state to state.”
Barnes and colleagues investigated associations of this spending with 5-year OS according to race and ethnicity, in addition to cancer site, among nearly 3 million adults newly diagnosed with cancer from 2007 to 2016.
The researchers reviewed patient data from the SEER program, including data from 13 states, and annual state spending data from the U.S. Census Bureau. They adjusted analyses for age, sex, metropolitan residence, state, county-level income and education, and insurance status, as well as for disease factors, including cancer site, stage at diagnosis and year of diagnosis.
Five-year OS served as the primary outcome. Cluster-robust regression models that accounted for several covariates enabled researchers to estimate associations between public welfare spending and survival.
Key findings
Results showed 10.8% lower 5-year OS among Black patients compared with white patients for all cancers combined.
Researchers found no association between public welfare spending and 5-year OS overall or among white patients. However, they did find an association among Black patients, who demonstrated an 8.62% (95% CI, 4.62-12.62) increase in 5-year OS with 10% higher public welfare spending.
For each 10% spending increase, the 5-year OS disparity between Black and white patients narrowed 4.55% (95% CI, 2.76-6.35). Among specific cancer types, each 10% spending increase corresponded with an increase in 5-year OS among Black patients of:
- 14.1% for uterine cancer, for a 40% reduction of the disparity vs. white patients;
- 11.9% for cervical cancer, for a 46% disparity reduction;
- 9.41% for head and neck cancer, for a 38% disparity reduction;
- 8.95% for ovarian cancer, for a 41% disparity reduction;
- 8.18% for bladder cancer, for a 44% disparity reduction;
- 7.02% for liver cancer, for a 49% disparity reduction;
- 6.15% for breast cancer, for a 39% disparity reduction; and
- 4.42% for colorectal cancer, for a 48% disparity reduction.
Researchers observed similar results after accounting for state limits on Medicaid eligibility and excluding Medicaid expansion-related data.
“The findings were largely unsurprising, as the proposed mechanism — overcoming disparities rooted in social determinants of health directly through public welfare spending — makes sense,” Barnes told Healio. “However, in some subgroup analyses, namely age subgroups, there were no public welfare spending-associated improvements in OS for non-elderly patients, as these improvements were limited to elderly patients with cancer.”
Implications
The study results highlight the benefits of government investment in social services to reduce cancer care disparities, according to the researchers.
“Public welfare investment improves oncologic outcomes for some of our most socioeconomically at-risk patients, such as non-Hispanic Blacks, and narrows racial disparities,” Barnes told Healio. “However, I view these hypothesis-generating data as a proof-of-concept, since we don’t yet know the specifics. As we learn more about the specific policies and expenditures that are most influential in improving cancer outcomes, it will be our role as clinicians and scientists to advocate for such policies to improve outcomes for all our patients and help to close the gap in racial disparities in oncologic outcomes.”
Perspective
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Julie R. Gralow, MD, FACP, FASCO
We know that state public welfare spending can mitigate structural racism and at least partially address social determinants of health, such as financial stability, education, place of residence and insurance status. This research found that states that increased public welfare spending have improved overall survival for Black patients with a variety of solid tumors, and this also resulted in a decrease in racial disparities in survival between non-Hispanic Black and white patients.
These important data provide clear support for the benefits of an investment in public welfare spending at the state level, including Medicaid expansion.
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Barnes JM, et al. Abstract 6509. Scheduled for presentation at: ASCO Annual Meeting; June 3-7, 2022; Chicago.
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