Racial Disparities Persist in GI Cancers and Beyond

Marcus S. Noel, MD

Racial disparities affecting all aspects of patient care are a major issue across cancer types, including for patients with gastrointestinal (GI) cancers, according to data presented by Marcus S. Noel, MD, at the 6th Annual School of Gastrointestinal Oncology^®.¹

“Racial disparities in health care are well-documented and [extend] back to the start of this country,” explained Noel, an associate professor of medicine at the Georgetown Lombardi Comprehensive Cancer Center in Washington, DC. Studies have shown that racial and ethnic minorities receive a lower quality of health care even when income and access are taken into consideration. Rates of screening for cancers are low in minority patients and death rates due to disease are disproportionately high, Neal added.

Between 2010 and 2016 the 5-year relative survival rate for white patients across cancer types was 68%, compared with 62% for black patients.1 Overall cancer incidence rates for black men were the highest reported at 540.0 per 100,000 population, compared with 501.2 per 100,000 for white men. Further, mortality rates for all cancer sites combined was 186.4 per 100,000 for black patients vs 162.9 per 100,000 for white patients.²

GI Cancers Shine a Light on Gaps in Care

In GI cancers specifically, data have shown that black patients display a higher incidence of colorectal cancers compared with other ethnic groups. In data from 2012 through 2016, the incidence rates of colorectal cancer in black patients were approximately 20% higher than in non-Hispanic white patients at 45.7 per 100,000 and 38.6 per 100,000 population, respectively. These trends extended by sex as well. In non-Hispanic black men the incidence of colorectal cancer incidence was 53.8 per 100,000, compared with 44.0 per 100,000 in non-Hispanic white men.3 The incidence rates were 39.9 per 100,000 for black women and 33.9 per 100,000 for white women.³

Black patients also have a higher morality due to colorectal cancers when compared with other groups. The mortality rate due to colorectal cancer was 19.0 per 100,000 for black patients, compared with 13.8 per 100,000 for non-Hispanic white patients. The greatest disparity was observed between black men and non-Hispanic white men with reported mortality rates of 23.8 per 100,000 and 16.3 per 100,000, respectively.³

Disparities also exist in other GI cancer types. For example in a review of patients with pancreatic cancer, investigators reported that non-Hispanic white patients were offered surgical resection more often than black patients (27.5% vs 22.9%, respectively; P < .001).4Black patients were also more likely to refuse surgery than non-Hispanic white patients (5.4% vs 4.1%) and were reported less likely to receive chemotherapy (HR, 0.61; 95% CI, 0.37-0.95).⁴

“Race is a poor proxy for ancestry, which is linked to genetics,” Noel said. “Certainly, there are some genetic differences that may play a role in cancer disparities, but I would argue that a larger piece of the disparity is actually due to socioeconomics, insurance, and other factors.”

A review of 473,722 patients diagnosed with one of the 10 most deadly cancers, analyzed the association of insurance status in relation to disease stage at diagnosis, treatment, and survival among patients. Results showed that patients with non-Medicaid insurance were less likely to present with distant disease (16.9%) than those with Medicaid coverage (29.1%) or those without insurance coverage (34.7%; P < .001).5 Patients with non-Medicaid insurance were also more likely to receive cancer-directed surgery and/or radiation therapy (79.6%), compared with 67.9% of those with Medicaid coverage and 62.1% of patients without insurance coverage (P < .001).⁵

Social Determinants of Health May Provide Some Guidance

Black patients’ lack of trust in the medical community is certainly a contributing factor to disparities in care that is long withstanding, perpetuated by events like the Tuskegee Syphilis Study.¹ Noel also noted that the often-long distances between the black community and quality health care providers and facilities represents a major obstacle in obtaining quality care.

“It’s really about efforts in the community,” Noel said. “Education is so important, many of our underserved communities do not have a level of education that’s equal to our peers. Without the education, the ability to understand the complexities of medical care, often times patients may make the wrong decision in their care.”

Efforts to achieve incremental cost effectiveness of interventions for patients with cancer should look to leverage social determinants of health to improve cancer screening, Neal added. Results of a systematic review of economic evaluations of interventions leveraging social determinants of health to improve screening for breast, cervical, and colorectal cancer to guide implementation showed that interventions appear to be cost-effective for underserved and vulnerable populations in the United States.⁶

The median cost for all interventions was $123.87 (interquartile interval [IQI] $24.44-$313.19), with a median cost for colorectal cancer screening was approximately $46.00, Neal said. The median incremental cost per additional person screened was $250.37 (IQI, $44.67-$609.38). Further, the median incremental cost per quality-adjusted life-year gained was $3120.00, which the authors concluded was considerably lower than an established conservative threshold for cost-effectiveness.

Notably, investigators also showed a median incremental screening rate of 15% (IQI, 14%-20%).6 Although screening has increased, disparities in care exist for early detection as Black patients are more likely to receive a diagnosis at later stages of disease because of reduced opportunity to engage in effective physician-patient communication.⁷ Specifically for patients with colorectal cancer, approximately 5.5% of all diagnoses of colorectal cancer are made prior to 50 years of age in non-Hispanic Whites, whereas for Black patients, approximately 10.6% occur prior to age 50. This patient population requires increased access to information including risk factors for colorectal cancer, access to testing, and other barriers to care.

“This also applies on the medical side; it’s important to increase the number of minority physicians, nurses, and researchers,” Neal concluded. “Many black families do not have access to a black physician or a black health care worker, and [therefore may lose] the ability to call with questions and that level of support when going through a diagnosis.”

References

1. Noel MS. GI Cancer Health Disparities. Poster presented at 6th Annual School of Gastrointestinal Oncology; March 20, 2021. Accessed March 22, 2021.
2. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2020. CA Cancer J Clin. 2020;70(1):7-30. doi:10.3322/caac.21590
3. Siegel RL, Miller KD, Goding SA, et al. Colorectal cancer statistics, 2020. CA A Cancer J Clin. 2020;70(3):145-64. doi:10.3322/caac.21601
4. Noel M, Fiscella K. Disparities in pancreatic cancer treatment and outcomes. Health Equity. 2019;3(1):532-40. doi:10.1089/heq.2019.0057
5. Walker GV, Grant SR, Guadagnolo BA, et al. Disparities in stage at diagnosis, treatment, and survival in nonelderly adult patients with cancer according to insurance status. J Clin Oncol. 2014;32(28):3118-25. doi:10.1200/jco.2014.55.6258
6. Mohan G, Chattopadhyay S. Cost-effectiveness of leveraging social determinants of health to improve breast, cervical, and colorectal cancer screening. JAMA Oncol. 2020;6(9):1434-1444. doi:10.1001/jamaoncol.2020.1460
7. Jackson CS, Oman M, Patel AM, Vega KJ. Health disparities in colorectal cancer among racial and ethnic minorities in the United States. J Gastrointest Oncol. 2016;7(suppl 1):S32-43. doi:10.3978/j.issn.2078-6891.2015.039