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November 08, 2023
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Race linked to quality, timeliness of care in adults with early-onset colorectal cancer

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Key takeaways:

  • Significant racial disparities occurred during every step of the cancer care continuum.
  • Health insurance identified as largest contributing factor to racial disparities in receiving guideline-concordant care.
Perspective from Suneel Kamath, MD

Black individuals with early-onset colorectal cancer received worse and less timely care compared with white patients, according to results of a national hospital-based study.

Of note, researchers identified health insurance as the largest contributing modifiable factor of racial disparities in receipt of guideline-concordant care among the study population.

Proportion of patients who did not receive guideline-concordant care infographic
Data derived from Nogueira LM, et al. J Clin Oncol. 2023;doi:10.1200/JCO.23.00539.

Rationale and methodology

“Colorectal cancer incidence and mortality rates are increasing among young adults in the U.S., and individuals racialized as Black have worse survival after diagnosis of early-onset colorectal cancer than individuals racialized as white,” Leticia M. Nogueira, PhD, MPH, scientific director of health services research at American Cancer Society, told Healio. “This research is needed to identify modifiable factors contributing to this disparity.”

Investigators examined racial disparities in receipt of timely and guideline-concordant care — staging, surgery, lymph node evaluation, chemotherapy and radiotherapy — among 84,882 patients with early-onset colon cancer and 62,573 patients with rectal cancer identified by race as either Black or white and included in the National Cancer Database between 2004 and 2019.

Researchers used the decomposition method to estimate the relative contribution of demographic characteristics, comorbidities, health insurance and facility type to the racial disparity in receipt of guideline-concordant care.

They additionally used the product-limit method to evaluate differences in time to treatment between patients identified as Black vs. white.

Findings

Overall, Black patients comprised 20.8% of colon cancer cases and 14.5% of rectal cancers.

Results showed a higher likelihood to not receive guideline-concordant care among Black patients with early-onset colon cancer (36.6% vs. 32.9%; adjusted OR = 1.18; 95% CI, 1.14-1.22) and early-onset rectal cancer (62.3% vs. 56.5%; adjusted OR = 1.27; 95% CI, 1.21-1.33) compared with white patients.

Moreover, researchers identified health insurance as the most significant factor contributing to racial disparity among 28.2% of patients with colon cancer and 21.6% of patients with rectal cancer.

Results also showed that compared with white patients, Black patients experienced increased time to adjuvant chemotherapy for colon cancer (HR = 1.28; 95% CI, 1.24-1.32) and neoadjuvant chemoradiation for rectal cancer (HR = 1.42; 95% CI, 1.37-1.47).

Black patients who began radiotherapy for rectal cancer also experienced significantly longer time to completion of their treatment regimen compared with white patients (HR = 1.19; 95% CI, 1.13 to 1.25).

“There were significant disparities in receipt of guideline-concordant care at every step, including cancer staging — the very first step,” Nogueira said. “If the tumor is not staged, oncologists are not able to determine eligibility to different types of treatment, such as surgery or chemotherapy.

“However, the most surprising finding was the significant disparity in lymph node evaluation,” she continued. “Lymph nodes are extracted while the patient is in the operating room. Therefore, factors frequently posed as potential contributors to racial disparities do not play a role in receipt of guideline-concordant lymph node evaluation. Moreover, individuals racialized as Black were less likely to receive guideline-concordant lymph node evaluation even though they were more likely to be treated at high-performing facilities.”

Additional research needs

Clinicians need to evaluate current practices that might be contributing to racial disparities in receipt of guideline-concordant care, Nogueira told Healio.

“Additionally, cancer centers’ performance could be evaluated overall and by racialized groups, which would provide an incentive for providing equitable care,” she said. “Additional research is needed on interventions at the provider, institutional and policy level for addressing racial disparities in receipt of quality care for early-onset colorectal cancer.”