Intestinal tumor, artwork
Credit: JUAN GARTNER/Getty Images

Adult African-American cancer patients are more likely than white patients to receive substandard surgical care for their gastrointestinal cancer, according to a large study led by researchers at Yale Cancer Center. The findings, which appeared in the 4 April 2022 issue of the journal JAMA Network Open, highlight lapses in the healthcare system by medical providers and hospital systems.

“Changes are needed to address and eradicate root causes of disparities in the treatment of gastrointestinal cancers,” said Dr. Sajid Khan, associate professor of surgery (Oncology), section chief of Hepato-Pancreato-Biliary (HPB) and Mixed Tumors at Yale Cancer Center, and senior author of the study.

According to the American Cancer Society, gastrointestinal cancers account for 35% of cancer deaths. For the new study, researchers wanted to examine whether race-specific treatment disparities exist with curative intent surgery for these patients across the United States. They used outcome data from the National Cancer Database, specifically the clinical oncology database which captures 72 percent of newly diagnosed cancer cases nationwide. The study included data for a cohort of 565,124 adult patients with gastrointestinal cancer undergoing surgery between 2004 and 2017.

The researchers found that, compared to white patients, African-American patients had lower rates of negative surgical margins and were less likely to have adequate numbers of lymph nodes removed. Negative surgical margins and adequate lymphadenectomies are both standards of cancer surgery care and were associated with longer median survival (87.3 vs 22.9 months and 80.7 vs 57.6 months, respectively). African-American patients were also 68 percent more likely to not receive recommended chemotherapy and 118 percent more likely to not receive recommended radiation therapy than white patients after surgery for unknown reasons.

Social and economic factors are major contributors to health disparities. But, because Black people have a higher prevalence of pre-existing health conditions, that also likely accounts for the study’s findings. “For example,” Khan said, “diabetes is found at a higher rate in Blacks compared to whites. Diabetes is significantly associated with increased risk of cancer death.”

Khan said he and his colleagues plan to explore the national cohort data more closely, looking at the hospital level to better understand the socio-economic components to race-specific treatment disparities. “The beauty of the National Cancer Database is that it allows for the identification of existing problems from a bird’s eye view, and provides clues as to where problems may exist,” he said. The researchers will be examining biases in medical providers and discrepancies in surgical and pathology equipment at treatment centers which primarily serve under-resourced communities.

Scientists at Yale University and other academic centers have shown differences in tumor biology exist based on race/ethnicity for specific types of gastrointestinal tract cancer.  This is evident in different frequencies of mutations, tumor aggressiveness, treatment responses, tumor metabolism, and  tumor microbiota. “Our labs will continue with basic science studies to better identify molecular and metabolic differences which drive cancer formation by race/ethnicity and enable for more effective treatment interventions,” he said.

Addressing health disparities means better training for the next generation of medical providers, Khan said. “We suspect a communication gap exists between providers and patients, one which can be narrowed,” he said. Khan pointed out that a notable finding of his studies is that Black people and Native American people are more likely to not receive indicated postoperative chemotherapy and postoperative radiation therapy based on medical providers not recommending this treatment because of medical comorbidities and for unknown reasons. “This is despite Black and white patients equally refusing chemotherapy,” he said. “This result suggests a provider bias exists, and thus there is room for improving medical education and communication.”

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