Effects of individual-level socioeconomic factors on racial disparities in cancer treatment and survival: findings from the National Longitudinal Mortality Study, 1979-2003

BACKGROUND:

This is the first study to use the linked National Longitudinal Mortality Study and Surveillance, Epidemiology, and End Results (SEER) data to determine the effects of individual‐level socioeconomic factors (health insurance, education, income, and poverty status) on racial disparities in receiving treatment and in survival.

METHODS:

This study included 13,234 cases diagnosed with the 8 most common types of cancer (female breast, colorectal, prostate, lung and bronchus, uterine cervix, ovarian, melanoma, and urinary bladder) at age ≥25 years, identified from the National Longitudinal Mortality Study‐SEER data during 1973 to 2003. Kaplan‐Meier methods and Cox regression models were used for survival analysis.

RESULTS:

Three‐year all‐cause observed survival for cases diagnosed with local‐stage cancers of the 8 leading tumors combined was ≥82% regardless of race/ethnicity. More favorable survival was associated with higher socioeconomic status. Compared with whites, blacks were less likely to receive first‐course cancer‐directed surgery, perhaps reflecting a less favorable stage distribution at diagnosis. Hazard ratio (HR) for cancer‐specific mortality was significantly higher among blacks compared with whites (HR, 1.2; 95% confidence interval [CI], 1.1‐1.3) after adjusting for age, sex, and tumor stage, but not after further controlling for socioeconomic factors and treatment (HR, 1.0; 95% CI, 0.9‐1.1). HRs for all‐cause mortality among patients with breast cancer and for cancer‐specific mortality in patients with prostate cancer were significantly higher for blacks compared with whites after adjusting for socioeconomic factors, treatment, and patient and tumor characteristics.

CONCLUSIONS:

Favorable survival was associated with higher socioeconomic status. Racial disparities in survival persisted after adjusting for individual‐level socioeconomic factors and treatment for patients with breast and prostate cancer. Cancer 2011. © 2011 American Cancer Society.     

Racial disparities and survival for nonsmall‐cell lung cancer in a large cohort of black and white elderly patients

BACKGROUND:

This study aimed to examine disparities in survival and associated factors for patients with nonsmall‐cell lung cancer (NSCLC) and to determine whether racial disparities varied over time (1991‐1995, 1996‐1999, and 2000‐2002).

METHODS:

The authors studied 70,901 patients aged ≥65 years with stage I‐IV NSCLC identified from Surveillance, Epidemiology, and End Results/Medicare data. Multivariate time‐to‐event survival analyses were completed using Cox proportional regression modeling.

RESULTS:

The 5‐year observed lung cancer‐specific survival rates were 52.7% for whites and 47.5% for blacks with stage I‐II disease, and 17.7% and 19.6% for whites and blacks, respectively at stages III‐IV. After controlling for standard treatment, socioeconomic status (SES), and other factors, there were no significant differences in all‐cause mortality, or lung cancer‐specific mortality between black and white patients with stage I‐II or III‐IV lung cancer. However, blacks had an increased risk for overall all‐cause mortality at stage I‐IV (hazard ratio [HR], 1.24; 95% confidence interval, 1.13‐1.35), and during 2000‐2002 at stage III‐IV for all‐cause mortality (HR, 1.22; 95% CI, 1.02‐1.47) and lung cancer‐specific mortality (HR, 1.24; 95% CI,1.01‐1.53). Standard treatment was significantly associated with increased survival, whereas poor SES was associated with increased mortality.

CONCLUSIONS:

There were no significant differences in survival between blacks and whites with NSCLC within stage stratifications after adjusting for covariates, except for black patients at overall stage for all‐cause mortality and at stage III‐IV diagnosed in 2000‐2002. Receiving stage‐specific evidence‐based standard therapy was associated with significantly increased survival. Cancer 2009. © 2009 American Cancer Society.     

Racial variation in breast cancer treatment among Department of Defense beneficiaries

BACKGROUND:

Although the overall age‐adjusted incidence rates for female breast cancer are higher among whites than blacks, mortality rates are higher among blacks. Many attribute this discrepancy to disparities in health care access and to blacks presenting with later stage disease. Within the Department of Defense (DoD) Military Health System, all beneficiaries have equal access to health care. The aim of this study was to determine whether female breast cancer treatment varied between white and black patients in the DoD system.

METHODS:

The study data were drawn from the DoD cancer registry and medical claims databases. Study subjects included 2308 white and 391 black women diagnosed with breast cancer between 1998 and 2000. Multivariate logistic regression analyses that controlled for demographic factors, tumor characteristics, and comorbidities were used to assess racial differences in the receipt of surgery, chemotherapy, and hormonal therapy.

RESULTS:

There was no significant difference in surgery type, particularly when mastectomy was compared with breast‐conserving surgery plus radiation (blacks vs whites: odds ratio [OR], 1.1; 95% confidence interval [CI], 0.8‐1.5). Among those with local stage tumors, blacks were as likely as whites to receive chemotherapy (OR, 1.2; 95% CI, 0.9‐1.7) and hormonal therapy (OR, 1.0; 95% CI, 0.6‐1.4). Among those with regional stage tumors, blacks were significantly less likely than whites to receive chemotherapy (OR, 0.4; 95% CI, 0.2‐0.7) and hormonal therapy (OR, 0.5; 95% CI, 0.3‐0.8).

CONCLUSIONS:

Even within an equal access health care system, stage‐related racial variations in breast cancer treatment are evident. Studies that identify driving factors behind these within‐stage racial disparities are warranted. Cancer 2012;. © 2011 American Cancer Society.     

Racial variation in tumor stage at diagnosis among Department of Defense beneficiaries

BACKGROUND:

Tumor stage at diagnosis often varies by racial/ethnic group, possibly because of inequitable health care access. Within the Department of Defense (DoD) Military Health System, beneficiaries have equal health care access. The objective of this study was to determine whether tumor stage differed between whites and blacks with breast, cervical, colorectal, and prostate cancers, which have effective screening regimens, based on data from the DoD Automated Cancer Tumor Registry from 1990 to 2003.

METHODS:

Distributions of tumor stage (localized vs nonlocalized) between whites and blacks in the military were compared stratified by sex, active duty status, and age at diagnosis. Logistic regression was used to further adjust for age, marital status, year of diagnosis, geographic region, military service branch, and tumor grade. Distributions of tumor stage were then compared between the military and general populations.

RESULTS:

Racial differences in the distribution of stage were significant only among nonactive duty beneficiaries. After adjusting for covariates, earlier stages of breast cancer after age 49 years and prostate cancer after age 64 years were significantly more common among white than black nonactive duty beneficiaries (P < .05), although the absolute difference was minimal for prostate cancer. Racial differences in stage for cervical and colorectal cancers were not significant after adjustment. Compared with the general population, racial differences in the military were similar or were slightly attenuated.

CONCLUSIONS:

Racial disparities in stage at diagnosis were apparent in the DoD equal‐access health care system among older nonactive duty beneficiaries. Socioeconomic status, supplemental insurance, cultural beliefs, and biologic factors may be related to these results. Cancer 2012;. © 2011 American Cancer Society.     

Effects of health insurance and race on early detection of cancer.

BACKGROUND: The presence and type of health insurance may be an important determinant of cancer stage at diagnosis. To determine whether previously observed racial differences in stage of cancer at diagnosis may be explained partly by differences in insurance coverage, we studied all patients with incident cases of melanoma or colorectal, breast, or prostate cancer in Florida in 1994 for whom the stage at diagnosis and insurance status were known. METHODS: The effects of insurance and race on the odds of a late stage (regional or distant) diagnosis were examined by adjusting for an individual's age, sex, marital status, education, income, and comorbidity. All P values are two-sided. RESULTS: Data from 28 237 patients were analyzed. Persons who were uninsured were more likely diagnosed at a late stage (colorectal cancer odds ratio [OR] = 1.67, P =.004; melanoma OR = 2.59, P =.004; breast cancer OR = 1.43, P =.001; prostate cancer OR = 1.47, P =.02) than were persons with commercial indemnity insurance. Patients insured by Medicaid were more likely diagnosed at a late stage of breast cancer (OR = 1.87, P<.001) and melanoma (OR = 4.69, P<.001). Non-Hispanic African-American patients were more likely diagnosed with late stage breast and prostate cancers than were non-Hispanic whites. Hispanic patients were more likely to be diagnosed with late stage breast cancer but less likely to be diagnosed with late stage prostate cancer. CONCLUSIONS: Persons lacking health insurance and persons insured by Medicaid are more likely diagnosed with late stage cancer at diverse sites, and efforts to improve access to cancer-screening services are warranted for these groups. Racial differences in stage at diagnosis are not explained by insurance coverage or socioeconomic status.     

Colorectal cancer incidence in the United States, 1999‐2004

BACKGROUND:

By using recent national cancer surveillance data, the authors investigated colorectal cancer (CRC) incidence by subpopulation to inform the discussion of demographic‐based CRC guidelines.

METHODS:

Data included CRC incidence (1999‐2004) from the combined National Program of Cancer Registries and Surveillance, Epidemiology, and End Results Program databases. Incidence rates (age‐specific and age‐adjusted to the 2000 US standard population) were reported among individuals ages 40 to 44 years, 45 to 49 years, 50 to 64 years, and ≥65 years by sex, subsite, disease stage, race, and ethnicity. Rate ratios (RR) and rate differences (RD) were calculated to compare CRC rates in different subpopulations.

RESULTS:

Incidence rates were greater among men compared with women and among blacks compared with whites and other races. Incidence rates among Asians/Pacific Islanders (APIs), American Indians/Alaska Natives (AI/ANs), and Hispanics consistently were lower than among whites and non‐Hispanics. Sex disparities were greatest in the population aged ≥65 years, whereas racial disparities were more pronounced in the population aged <65 years. Although the RD between blacks and whites diminished at older ages, the RD between APIs and whites, between AI/ANs and whites, and between non‐Hispanics and Hispanics increased with increasing age. By subsite, blacks had the highest incidence rates compared with whites and other races in the proximal and distal colon; the reverse was true in the rectum. By stage, whites had higher incidence rates than blacks and other races for localized and regional disease; for distant and unstaged disease, blacks had higher incidence rates than whites.

CONCLUSIONS:

The current findings suggested differences that can be considered in formulating targeted screening and other public health strategies to reduce disparities in CRC incidence in the United States. Cancer 2009. Published 2009 by the American Cancer Society.     

Disparities in Breast Cancer Treatment and Outcomes: Biological,Social, and Health System Determinants and Opportunities for Research

Racial disparities in breast cancer mortality have been widely documented for several decades and persist despite advances in receipt of mammography across racial groups. This persistence leads to questions about the roles of biological, social, and health system determinants of poor outcomes. Cancer outcomes are a function not only of innate biological factors but also of modifiable characteristics of individual behavior and decision making as well as characteristics of patient‐health system interaction and the health system itself. Attempts to explain persistent racial disparities have mostly been limited to discussion of differences in insurance coverage, socioeconomic status, tumor stage at diagnosis, comorbidity, and molecular subtype of the tumor. This article summarizes existing literature exploring reasons for racial disparities in breast cancer mortality, with an emphasis on treatment disparities and opportunities for future research. Because breast cancer care requires a high degree of multidisciplinary team collaboration, ensuring that guideline recommended treatment (such as endocrine therapy for hormone receptor positive patients) is received by all racial/ethnic groups is critical and requires coordination across multiple providers and health care settings. Recognition that variation in cancer care quality may be correlated with race (and socioeconomic and health system factors) may assist policy makers in identifying strategies to more equally distribute clinical expertise and health infrastructure across multiple user populations.     

Racial and ethnic differences in lymph node examination after colon cancer resection do not completely explain disparities in mortality

BACKGROUND:

In 1999, a multidisciplinary panel of experts in colorectal cancer reviewed the relevant medical literature and issued a consensus recommendation for a 12‐lymph node (LN) minimum examination after resection for colon cancer. Some authors have shown racial/ethnic differences in receipt of this evidence‐based care. To date, however, none has investigated the correlation between disparities in LN examination and disparities in outcomes after colon cancer treatment.

METHODS:

This retrospective analysis used California Cancer Registry linked to California Office of Statewide Health Planning and Development discharge data (1996‐2006). Chi‐square analysis, logistic regression, and Cox proportional hazard models predicted disparities in receipt of an adequate examination and the effect of an inadequate exam on mortality and disparities. Patients with stage I and II colon cancers undergoing surgery in California were included; patients with stage III and IV disease were excluded.

RESULTS:

A total of 37,911 records were analyzed. Adequate staging occurred in fewer than half of cases. An inadequate examination (<12 LNs) was associated with higher mortality rates. Hispanics had the lowest odds of receiving an adequate exam; however, blacks, not Hispanics, had the highest risk of mortality compared with whites. This disparity was not completely explained by inadequate LN examination.

CONCLUSIONS:

Inadequate LN exam occurs often and is associated with increased mortality. There are disparities in receipt of the minimum exam, but this only explains a small part of the observed disparity in mortality. Improving the quality of LN examination alone is unlikely to correct colon cancer disparities. Cancer 2011;. © 2011 American Cancer Society.     

Influenza vaccination among cancer survivors: disparities in prevalence between blacks and whites

Introduction

Cancer survivors are at increased risk for influenza-related complications. Racial disparities in preventive health services have not been extensively studied among cancer survivors. Our objective is to compare influenza vaccination prevalence among black and white cancer survivors

Methods

We performed a secondary data analysis of 41,346 white and black cancer survivors (excluding non-melanoma skin cancer) from the 2009 Behavioral Risk Factor Surveillance System survey. Respondents were asked whether they had received an influenza vaccination in the previous year. Multivariable logistic regression was used to estimate the odds of having influenza vaccine by race.

Results

Sixty-five percent of whites reported receiving the vaccine in the last year compared to 50 % of blacks. Blacks had significantly lower odds of vaccination after controlling for covariates significantly associated with the odds of influenza vaccination. Higher education, having health insurance, having a primary care provider, and having a routine check-up in the last year increased the odds of receiving an influenza vaccine.

Conclusions

Our analysis supports that racial disparities in vaccine coverage persist among cancer survivors, a group strongly recommended to receive annual influenza vaccine, even when predictors significantly associated with increased vaccination are controlled for.

Implications for Cancer Survivors

As a nationally representative survey with a large sample size, our study provides a picture of self-reported vaccine coverage among cancer survivors in the USA and the disparity that exists between blacks and whites in this population. Care teams can use these findings to better target follow-up care for cancer survivors.     

Racial disparities in the use of radiotherapy after breast‐conserving surgery: A national Medicare study

BACKGROUND:

In prior studies, the use of standard breast cancer treatments has varied by race, but previous analyses were not nationally representative. Therefore, in a comprehensive, national cohort of Medicare patients, racial disparities in the use of radiotherapy (RT) after breast‐conserving surgery (BCS) for invasive breast cancer were quantified.

METHODS:

A national Medicare database was used to identify all beneficiaries (age >65 years) treated with BCS for incident invasive breast cancer in 2003. Claims codes identified RT use, and Medicare demographic data indicated race. Logistic regression modeled RT use in white, black, and other‐race patients, adjusted for demographic, clinical, and socioeconomic covariates.

RESULTS:

Of 34,080 women, 91% were white, 6% were black, and 3% were another race. The mean age of the patients was 76 ± 7 years. Approximately 74% of whites, 65% of blacks, and 66% of other‐race patients received RT (P < .001). After covariate adjustment, whites were found to be significantly more likely to receive RT than blacks (odds ratio, 1.48; 95% confidence interval, 1.34‐1.63 [P < .001]). Disparities between white and black patients varied by geographic region, with blacks in areas of the northeastern and southern United States demonstrating the lowest rates of RT use (57% in these regions). In patients age <70 years, racial disparities persisted. Specifically, 83% of whites, 73% of blacks, and 78% of other races in this younger group received RT (P < .001).

CONCLUSIONS:

In this comprehensive national sample of older breast cancer patients, substantial racial disparities were identified in RT use after BCS across much of the United States. Efforts to improve breast cancer care require overcoming these disparities, which exist on a national scale. Cancer 2010. © 2009 American Cancer Society.     

Having health insurance does not eliminate race/ethnicity-associated delays in breast cancer diagnosis in the District of Columbia

BACKGROUND:

Delays in follow‐up after breast cancer screening contribute to disparities in breast cancer outcomes. The objective of this research was to determine the impact of race/ethnicity and health insurance on diagnostic time, defined as number of days from suspicious finding to diagnostic resolution.

METHODS:

This retrospective cohort study of 1538 women examined for breast abnormalities between 1998‐2010 at 6 hospitals/clinics in the District of Columbia measured mean diagnostic times between non‐Hispanic whites (NHWs), non‐Hispanic blacks (NHBs), and Hispanics with private, government, or no health insurance by using a full‐factorial ANOVA model.

RESULTS:

Respective average—geometric mean (95% CI)—diagnostic times (in days) for NHWs, NHBs, and Hispanics were 16 (12, 21), 27 (23, 33), and 51 (35, 76) among privately insured; 12 (7, 19), 39 (32, 48), and 71 (48, 105) among government insured; 45 (17, 120), 60 (39, 92), and 67 (56, 79) among uninsured. Government insured NHWs had significantly shorter diagnostic times than government insured NHBs (P = .0003) and Hispanics (P < .0001). Privately insured NHWs had significantly shorter diagnostic times than privately insured NHBs (P = .03) and Hispanics (P < .0001). Privately insured NHBs had significantly shorter diagnostic times than uninsured NHBs (P = .03).

CONCLUSIONS:

Insured minorities waited >2 times longer to reach their diagnostic resolution than insured NHWs. Having private health insurance increased the speed of diagnostic resolution in NHBs; however, their diagnostic time remained significantly longer than for privately insured NHWs. These results suggest diagnostic delays in minorities are more likely caused by other barriers associated with race/ethnicity than by insurance status. Cancer 2011;. © 2011 American Cancer Society.     

Insurance status and survival disparities among nonelderly rectal cancer patients in the National Cancer Data Base

BACKGROUND:

Among patients with colorectal cancer, insurance status is associated with disparities in survival as well as differences in stage and treatment. The role of stage and treatment differences in these survival disparities is not clear because insurance status is also strongly correlated with race/ethnicity, socioeconomic status, and other factors.

METHODS:

The authors used data from the National Cancer Data Base, a national hospital‐based cancer registry, to examine insurance status and other factors related to survival among 19,154 rectal cancer patients aged 18 to 64 years. The authors examined the impact of 10 factors on 5‐year survival: age, sex, race/ethnicity, histologic grade, histologic subtype, neighborhood education and income levels, facility type, stage, and treatment.

RESULTS:

Adjusted only for age, the hazard ratio (HR) for death at 5 years was 1.00 (referent) among privately insured patients, 2.05 (95% confidence interval [CI], 1.89‐2.23) among Medicaid‐insured patients, and 2.01 (95% CI, 1.84‐2.19) among uninsured patients. After adjustment for all factors other than stage and treatment, the HRs were 1.88 (95% CI, 1.722.04) for Medicaid‐insured patients and 1.84 (95% CI, 1.69‐2.01) for uninsured patients. After further adjustment for stage and treatment, the HRs were 1.34 (95% CI, 1.22‐1.46) for Medicaid‐insured patients and 1.29 (95% CI, 1.18‐1.42) for uninsured patients.

CONCLUSIONS:

After adjustment for age, further adjustment for 9 other factors reduced the excess mortality among rectal cancer patients without private insurance by approximately 70%. Disparities in stage and treatment accounted for approximately 53% of the excess mortality, whereas factors other than stage and treatment accounted for approximately 17%. Cancer 2010. © 2010 American Cancer Society.     

Insurance and inpatient care: Differences in length of stay and costs between surgically treated cancer patients

BACKGROUND:

Early research demonstrated that patients' length‐of‐stay and inpatient costs varied according to their health insurance status. The authors of the current report studied a population‐based sample of privately insured, Medicaid‐insured, and uninsured inpatients ages 21 to 64 years who underwent surgical resection for either nonsmall cell lung cancer (NSCLC) (n = 781) or colorectal cancer (CRC) (n = 8190) or who underwent mastectomy (n = 6201) to compare length of stay and inpatient costs by insurance status.

METHODS:

Data for this study were derived from all civilian, acute‐care hospitals in Virginia from 1999 to 2005. Hierarchical generalized linear models were used to estimate the relation between the explanatory variables and lengths of stay and costs. All analyses controlled for patient characteristics and hospital random effects.

RESULTS:

Medicaid‐insured patients with NSCLC had longer lengths of stay (39% or 2.64 days longer) and higher inpatient costs (20% or $2479 higher costs). Uninsured and Medicaid‐insured patients with CRC had longer lengths of stay and higher inpatient costs. In contrast, uninsured patients with breast cancer had 11% shorter lengths of stay and 12% lower inpatient costs than privately insured patients. Medicaid‐insured patients had 10% lower inpatient costs than privately insured patients. Differences were no longer statistically significant when reconstruction was added to the models.

CONCLUSIONS:

Health insurance affected the need for health care and the amount of health care received. Uninsured and Medicaid‐insured patients with lung cancer and colon cancer who underwent resection had longer lengths of stay and higher inpatient costs than privately insured patients, but they had shorter lengths of stay when reconstruction was not provided. Among the patients with breast cancer, patients and/or providers economized on discretionary procedures. Cancer 2012. © 2012 American Cancer Society.     

Racial differences in prostate-specific antigen levels in patients with local-regional prostate cancer.

Prostate cancer is a significant health problem for blacks. The incidence and mortality rates are higher in blacks than in whites; blacks often present with a higher stage. Prostate-specific antigen (PSA) is a very useful serum marker in prostate cancer. We analyzed data from a cohort of 161 patients to determine whether there were any racial differences in PSA levels prior to treatment in local-regional prostate cancer. The immunoradiometric method was used to determine the PSA values. The mean PSA levels were significantly higher in blacks than in whites (P = 0.022), and the difference remained significant in multivariate analysis after adjusting for stage and grade (P = 0.020). However, when analyzed further, the difference was statistically significant in one hospital (P = 0.001) and not in another (P = 0.493). Thus, our results are not unequivocal, but our data do suggest that racial differences in PSA levels not accounted for by tumor stage or grade may exist. Assuming that the data truly reflect a racial difference, the cause(s) of this difference remains to be determined. It may exist because, within each clinical stage, blacks are presenting with a higher tumor cell burden, or it may be indicative of more aggressive biological behavior. The possibility that racial differences are due to socioeconomic factors was considered by estimating median income level from zip code of residence; although a correlation between socioeconomic status and PSA level was found, racial differences remained borderline significant (P = 0.055) after adjusting for income level (in addition to stage and grade).     

Cancer mortality-to-incidence ratios in Georgia: describing racial cancer disparities and potential geographic determinants

BACKGROUND:

The objective of this study was to evaluate racial cancer disparities in Georgia by calculating and comparing mortality‐to‐incidence ratios (MIRs) by health district and in relation to geographic factors.

METHODS:

Data sources included cancer incidence (Georgia Comprehensive Cancer Registry), cancer mortality (Georgia Vital Records), and health factor (County Health Rankings) data. Age‐adjusted incidence and mortality rates were calculated by cancer site (all sites combined, lung, colorectal, prostate, breast, oral, and cervical) for 2003‐2007. MIRs and 95% confidence intervals were calculated overall and by district for each cancer site, race, and sex. MIRs were mapped by district and compared with geographic health factors.

RESULTS:

In total, 186,419 incident cases and 71,533 deaths were identified. Blacks had higher MIRs than whites for every cancer site evaluated, and especially large differentials were observed for prostate, cervical, and oral cancer in men. Large geographic disparities were detected, with larger MIRs, chiefly among blacks, in Georgia compared with national data. The highest MIRs were detected in west and east central Georgia, and the lowest MIRs were detected in and around Atlanta. Districts with better health behavior, clinical care, and social/economic factors had lower MIRs, especially among whites.

CONCLUSIONS:

More fatal cancers, particularly prostate, cervical, and oral cancer in men were detected among blacks, especially in central Georgia, where health behavior and social/economic factors were worse. MIRs are an efficient indicator of survival and provide insight into racial cancer disparities. Additional examination of geographic determinants of cancer fatality in Georgia as indicated by MIRs is warranted. Cancer 2012. © 2012 American Cancer Society     

Racial disparities in colorectal cancer survival

BACKGROUND:

Racial/ethnic differences in colorectal cancer (CRC) survival have been documented throughout the literature. However, the reasons for these disparities are difficult to decipher. The objective of this analysis was to determine the extent to which racial/ethnic disparities in survival are explained by differences in sociodemographics, tumor characteristics, diagnosis, treatment, and hospital characteristics.

METHODS:

A cohort of 37,769 Medicare beneficiaries who were diagnosed with American Joint Committee on Cancer stages I, II, and III CRC from 1992 to 2002 and resided in 16 Surveillance, Epidemiology, and End Results (SEER) regions of the United States was identified in the SEER‐Medicare linked database. Survival was estimated using the Kaplan‐Meier method. Cox proportional hazards modeling was used to estimate hazard ratios (HRs) of mortality and 95% confidence intervals (CIs).

RESULTS:

Black patients had worse CRC‐specific survival than white patients, but the difference was reduced after adjustment (adjusted HR [aHR], 1.24; 95% CI, 1.14‐1.35). Asian patients had better survival than white patients after adjusting for covariates (aHR, 0.80; 95% CI, 0.70‐0.92) for stages I, II, and III CRC. Relative to Asians, blacks and whites had worse survival after adjustment (blacks: aHR, 1.56; 95% CI, 1.33‐1.82; whites: aHR, 1.26; 95% CI, 1.10‐1.44). Comorbidities and socioeconomic Status were associated with a reduction in the mortality difference between blacks and whites and blacks and Asians.

CONCLUSIONS:

Comorbidities and SES appeared to be more important factors contributing to poorer survival among black patients relative to white and Asian patients. However, racial/ethnic differences in CRC survival were not fully explained by differences in several factors. Future research should further examine the role of quality of care and the benefits of treatment and post‐treatment surveillance in survival disparities. Cancer 2010. © 2010 American Cancer Society.     

Examining Racial Disparities in Colorectal Cancer Care

African Americans are disproportionately burdened with colorectal cancer. Although incidence and mortality rates have declined in the past two decades, the disparity in health outcomes has progressively increased. This comprehensive review examines the existing literature regarding racial disparities in colorectal cancer screening, stage at diagnosis, and treatment to determine if differences exist in the quality of care delivered to African Americans. A comprehensive review of relevant literature was performed. Two databases (EBSCOHOST Academic Search Premier and Scopus) were searched from 2000 to 2007. Articles that assessed racial disparities in colorectal cancer screening, stage of disease at diagnosis, and treatment were selected. The majority of studies identified examined colorectal cancer screening outcomes. Although racial disparities in screening have diminished in recent years, African American men and women continue to have higher colorectal cancer incidence and mortality rates and are diagnosed at more advanced stages. Several studies regarding stage of disease at diagnosis identified socioeconomic status (SES) and health insurance status as major determinants of disparity. However, some studies found significant racial disparities even after controlling for these factors. Racial disparities in treatment were also found at various diagnostic stages. Many factors affecting disparities between African Americans and Whites in colorectal cancer incidence and mortality remain unexplained. Although the importance of tumor biology, genetics, and lifestyle risk factors have been established, prime sociodemographic factors need further examination to understand variances in the care of African Americans diagnosed with colorectal cancer.     

Association Between Primary Payer Status and Survival in Patients With Stage III Colon Cancer: An National Cancer Database Analysis

Background

Colon cancer is the third most frequent cancer diagnosis, and primary payer status has been shown to be associated with treatment modalities and survival in cancer patients. The goal of our study was to determine the between-insurance differences in survival in patients with clinical stage III colon cancer using data from the National Cancer Database (NCDB).

Association of area sociodemographic characteristics and capacity for treatment with disparities in colorectal cancer care and mortality

BACKGROUND:

Disparities in treatment and mortality for colorectal cancer (CRC) may reflect differences in access to specialized care or other characteristics of the area where an individual lives.

METHODS:

Surveillance, Epidemiology and End Results Program–Medicare data for seniors diagnosed with CRC were linked to area measures of the sociodemographic characteristics and the capacity of surgeons, medical oncologists, and radiation oncologists. Outcomes included receipt of stage‐appropriate CRC care and mortality.

RESULTS:

After adjustment, blacks and Hispanics were less likely than whites to undergo surgery (odds ratio [OR] 0.57, 95% confidence interval (CI) 0.52‐0.63 and OR 0.82, 95% CI 0.70‐0.95, respectively). Individuals who lived in areas with the highest tertile of surgeon capacity were more likely to undergo resection than those in the lowest, and use of surgery declined as the percentage of blacks in the area increased. Adjustment for the area measures resulted in a modest decline in disparities in care relative to whites (5.3% for black). Blacks also experienced greater all‐cause and cancer‐specific mortality than whites. Further adjustment for area sociodemographics and surgeon capacity reduced the disparity in mortality between blacks and whites. Although there was a similar black/white disparity in the use of adjuvant chemotherapy, the disparity remained after adjustment for area characteristics, although use of chemotherapy was greater in areas with the greatest capacity of medical oncologists.

CONCLUSIONS:

Sociodemographic characteristics and measures of the availability of specialized cancer providers in the area in which an individual resides modestly mediated disparities in the receipt of CRC care and mortality, suggesting that other factors may also be important. Cancer 2011;. © 2011 American Cancer Society.     

Disparities in medical care among commercially insured patients with newly diagnosed breast cancer

BACKGROUND:

African‐American women have increased breast cancer mortality compared with white women. Diagnostic and treatment gaps may contribute to this disparity.

METHODS:

In this retrospective, longitudinal cohort study, Southern US health plan claims data and linked medical charts were used to identify racial disparities in the diagnoses, treatment, and mortality of commercially insured women with newly diagnosed breast cancer. White women (n = 476) and African‐American women (n = 99) with newly diagnosed breast cancer were identified by breast cancer claims codes (International Classification of Diseases, Ninth Revision, Clinical Modification codes 174, 233.0, 238.3, and 239.3) between January 2000 and December 2004. Race, diagnoses (breast cancer stage, estrogen/progesterone receptor [ER/PR]‐positive status), treatment (breast‐conserving surgery, antiestrogen therapy, and chemotherapy interruption or reduction), and all‐cause mortality were assessed from medical charts. Multivariate regression analyses were adjusted for age, geography, and socioeconomic status to test the association of race with diagnoses/treatment.

RESULTS:

White women were older (P < .001) and had higher rates of diagnosis at stage 0/I (55.2% vs 38.4%; P < .05) than African‐American women. More white women had positive ER/PR status (75% vs 56% African‐American; P = .001) and received antiestrogen therapy if they were positive (37.2% vs 27.3% African‐American; P < .001). White women received slightly more breast‐conserving surgery and chemotherapy dose modification than African‐American women (P value nonsignificant). African‐American women had a higher mortality rate (8.1%) than white women (3.6%; P = .06). In adjusted analyses, African‐American women were diagnosed at later stages (odds ratio, 1.71; P = .02), and white women received more antiestrogen therapy (odds ratio, 2.1; P = .03).

CONCLUSIONS:

Disparities in medical care among patients with newly diagnosed breast cancer were evident between African‐American women and white women despite health plan insurance coverage. Interventions that address the gaps identified are needed. Cancer 2010. © 2010 American Cancer Society.