Incarcerated adults at higher risk for cancer mortality
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Individuals diagnosed with cancer during incarceration or within a year after release from prison have a higher risk for cancer mortality than those never incarcerated, according to a study from Yale Cancer Center.
“This is a group that is protected by the Constitution — they are entitled to adequate health care and fair health care,” Oluwadamilola T. Oladeru, MD, MA, MBA, assistant professor of radiation oncology at University of Florida, told Healio. “If that’s not happening, we have to evaluate why.
“Also, our tax dollars are being used to provide care in these settings, especially from a state perspective,” Oladeru added. “So, we need to be able to answer questions on how we are doing as a society in taking care of one of the most vulnerable patient populations in oncology.”
Oladeru and colleagues conducted the study, funded by an NIH grant, using a statewide tumor registry linked with correctional system data. They evaluated data on 216,540 adults in Connecticut diagnosed with invasive cancer between 2005 and 2016, including 239 diagnosed in prison and 479 diagnosed within 12 months after release. After adjusting for demographics and cancer characteristics, they found a significantly higher 5-year risk for cancer-related death among those diagnosed while incarcerated (adjusted HR = 1.39; 95% CI, 1.12-1.73) and those diagnosed within a year of incarceration (adjusted HR = 1.82; 95% CI, 1.57-2.1) vs. the rest of the population. The groups also had a higher risk for all-cause mortality than those who had not been incarcerated.
Healio spoke with Oladeru about the challenges in collecting data on people who are incarcerated, the potential gaps in care in the corrections system and what can be done to change outcomes for this population.
Healio: How did you collect the data for this study?
Oladeru: We created a registry by linking data from the Connecticut Department of Corrections with data from the Department of Public Health and Connecticut Tumor Registry. We tracked individuals who were diagnosed with cancer while incarcerated, as well as those diagnosed with cancer within 12 months of release from prison.
The median age at diagnosis was 50 years for individuals with cancer in prison, 51 years for those diagnosed within 12 months of release and 66 years for those who were never incarcerated.
We also evaluated how long they had been incarcerated when they got their diagnosis. Those who were diagnosed in prison had been incarcerated for an average of 4.6 years. Those who were diagnosed in the recently released period had been in prison an average of 1.1 years. In terms of when they got their diagnosis, those in the recently released category got their diagnosis approximately 5 months after they were released from prison. Those diagnosed in prison got their diagnosis about 3.6 years after entering prison.
Healio: What did you learn in terms of the types of cancer these individuals had?
Oladeru: Among those with a history of criminal justice involvement, the most commonly diagnosed cancers were those of the gastrointestinal tract, including the colon and liver. Approximately 26% of those with a cancer diagnosis in prison and 33% of those recently released had GI cancers, compared with 17% of those in the never-incarcerated /residing in the community without criminal justice history group. It is sad, especially given that we have a screening test for colorectal cancers. Yet, these screenable cancers are being picked up much more in a younger population with a criminal justice history, meaning they are not being screened for these cancers.
Healio: At what stage were these cancers generally diagnosed?
Oladeru: Individuals were often diagnosed with cancer at locally advanced and metastatic stages — III and IV. We found that 42.7% of those in the incarcerated group with cancer were diagnosed at these later stages, as were 28.4% of those in the recently released group. So, there was a higher likelihood of a late-stage diagnosis or more locally advanced disease when you had a history of criminal justice involvement. Are symptoms being ignored while these individuals are incarcerated? We cannot say that factually.
Healio: Why do you think these individuals have a higher mortality risk?
Oladeru: It’s a complex question. People who are incarcerated tend to come from lower poverty brackets and underrepresented minority groups. They are from communities that already most likely had poor health status, and often upon release, they return to these same socioeconomically disadvantaged communities.
These individuals are probably also the population we’ve yet to reach with our screening guidelines, and they are entering prison with conditions that likely predispose them to developing cancer, even at an earlier age.
There is also the question of whether they are getting quality care when they are incarcerated. You can imagine the challenges of providing palliative care, cycles of chemotherapy or transportation to daily radiation treatments for someone in prison. We also know that a prison setting is not designed for multidisciplinary cancer care, and for such a complex medical diagnosis, it is overwhelming for oncologists to manage care for the patients while dealing with complex bureaucracy of carceral settings.
We’re also doing a deep dive into the medical records for a detailed clinical history and care delivery experience, with the goal of assessing the quality of cancer care incarcerated individuals receive. We hope to answer more of those concrete questions in subsequent aims of the grant.
Healio: What findings surprised you most?
Oladeru: What was surprising to us was that the mortality rates (both cancer-specific and all-cause) were worse for those in the recently released group compared with the currently incarcerated and never-incarcerated groups. We initially attributed it to the later-stage diagnosis, but upon adjustment for this potential factor, the high mortality rate persists. That suggests there are multifactorial challenges individuals who are recently released face upon transition to their communities. These include structural barriers that need to be overcome — securing housing, food and employment, as well as establishing relationships and social support. Getting a cancer screening is most likely going to be the last thing on your mind upon release from prison.
Healio: What is next for your research on this?
Oladeru: Our next steps are to look at how the quality of cancer care is impacted by incarceration status. Is it different for people who are diagnosed while in prison vs. those who are diagnosed immediately after incarceration? Our team also aims to identify challenges and propose solutions to obtaining high-quality cancer care in the correctional system. Our next steps include in-depth interviews with formerly incarcerated people diagnosed with cancer. We will inquire about the challenges they faced in accessing quality cancer care, their adherence to the recommended care, the timeliness of cancer care and participation in clinical trials. We are grateful for the collaboration with the Connecticut Department of Corrections on this study. It truly demonstrates openness to improving the status quo and serves as an example of the first step in this ongoing conversation about a critical issue in our prison system — cancer detection, treatment and survivorship.
For more information :
Oluwadamilola T. Oladeru, MD, MA, MBA, can be reached at University of Florida, 2000 SW Archer Road, Gainesville, FL 32611; email: ooladeru@ufl.edu.
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