SYSTEMIC RACISM 

Racial disparities in surgery rates for esophageal cancer

Black patients with esophageal cancer are less likely to receive life-saving surgery for early-stage disease than white patients

THOMAS JEFFERSON UNIVERSITY

PHILADELPHIA - Black patients with esophageal cancer are at a higher risk of death compared to white patients. Although many reasons have been suggested for this, few have given physician actionable information. A new study from the Sidney Kimmel Cancer Center (SKCC) - Jefferson Health points to a different reason - Black patients were less likely to receive surgery for treatable diseases, which could have contributed to their higher rates of death.

The results were published in the Journal of Gastrointestinal Surgery.

"National guidelines suggest that early-stage esophageal cancer should be treated with surgery because data shows that it offers patients the best chances of survival, rather than chemotherapy alone," says senior author Nathaniel Evans, MD, Director of the Division of Thoracic Surgery at Thomas Jefferson University, and Chief of Cancer Services, Center City Division at the SKCC. "Our data show that Black patients are not having surgery for early-stage disease, which may contribute to higher rates of death. With this data, we can now begin to educate patients and providers to change practice."

A total of 60,041 patients were included in the analysis that drew from the National Cancer Database, of whom 4,402 were Black and 55,639 were white across over 1,334 hospitals around the country. In order to ensure an unbiased comparison, Black and white patients were matched by demographics, comorbidities, and tumor characteristics in a 1:1 fashion. The final dataset included 5,858 patients.

The analysis led by first author Samantha L. Savitch, a senior medical student and researcher working in the Department of Surgery and others showed that rates of surgery were significantly lower, 25-40% less for Black patients with esophageal cancer in stages I to III. In addition, the researchers noted that the chances of getting surgery decreased as the age of Black patients increased, and also decreased if the patients were receiving radiation therapy. Black patients were more likely to get surgery if they were treated at a hospital that was more than 5 miles from their homes.

The findings also suggested that patients who were diagnosed with a type of esophageal cancer called squamous cell carcinoma, which is more common in Black patients, were less likely to receive surgery. All this despite clear evidence that surgical resection is the best chance for survival in patients with esophageal cancer.

"Although the data doesn't give us a reason for the observations we're seeing, it does show us areas where we can take action," says Dr. Evans. "Even when we control for socioeconomic status, insurance status, location, and comorbid conditions, the disparity still persists, it is quite profound. This highlights the need to educate Black patients and their healthcare providers on the importance of surgery in the treatment esophageal cancer."

"One way we are addressing this is by developing a Multidisciplinary GI Cancer group," says Dr. Evans. "We review esophageal cancer patients and ensure their treatment plans are tailored to the individual patent and follow established guidelines."

"This important study is part of a much larger effort at the Sidney Kimmel Cancer Center to understand and mitigate cancer disparities," says Karen Knudsen, PhD, EVP of Oncology Services and Enterprise Director of SKCC. "This goal is central to our mission to improve the lives cancer patients and their families, regardless of geography, gender, or demographic. We are thankful to Dr. Evans and the entire research team for raising awareness about this critical national issue."

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Article reference: Samantha L. Savitch, Tyler R. Grenda, Walter Scott, Scott W. Cowan, James Posey III, Edith P. Mitchell, Steven J. Cohen, Charles J. Yeo, Nathaniel R. Evans, "Racial Disparities in Rates of Surgery for Esophageal Cancer: a Study from the National Cancer Database," Journal of Gastrointestinal Surgery, DOI: 10.1007/s11605-020-04653-z, 2020.

Early-onset colorectal cancer study in young adult men reveals 'hotspots' of death in US

HUNTSMAN CANCER INSTITUTE

 CITY, UT - Over the last three decades, colorectal cancer survival in the United States has improved significantly. But in young people--particularly men diagnosed with colorectal cancer before age 50--incidence and mortality due to colorectal cancer are on the rise. Even among patients with early-stage colorectal cancer, racial disparities have grown more pronounced, with survival after colorectal cancer diagnosis poorer among African Americans compared with whites.

Charles R. Rogers, PhD, MPH, MS, Huntsman Cancer Institute (HCI) cancer researcher and assistant professor of public health at the University of Utah (U of U), is working to better understand these factors in young people with colorectal cancer in order to help improve outcomes

IMAGE: THIS IS A MAP OF COLORECTAL CANCER HOTSPOTS IN THE UNITED STATES. view more 

CREDIT: ROGERS ET AL. AMERICAN JOURNAL OF CANCER RESEARCH

and reduce related disparities from this preventable disease. A study led by Rogers and his colleagues, published in the American Journal of Cancer Research, found many of these new diagnoses are occurring in counties in the lower Mississippi Delta, west-central Appalachia, and eastern Virginia/North Carolina. These "hotspot" areas--where colorectal cancer is on the rise and actually killing young men at high rates--revealed several trends about who these men are and how their cancer progresses. The researchers found that young adult non-Hispanic Black men living in these areas are part of a group in which there is an alarming trend of increasing rates of early-onset colorectal cancer, and that these men are more likely to die of the disease as compared to other racial groups.

Rogers and his colleagues developed an analysis of counties with a high rate of early-onset colorectal cancer using data from Centers for Disease Control and Prevention during the years 1999 to 2017. They then linked this to Surveillance, Epidemiology, and End Results (SEER) Program data from the National Cancer Institute for men aged 15 to 49. This revealed 232 hotspot counties for early-onset colorectal cancer in the U.S. The majority of these counties are in the south.

The team then studied a variety of factors of the diagnoses in these hotspot counties. These included age, race, tumor stage and grade, treatment approach, and marital status. In the hotspot counties, they identified that death rates in non-Hispanic Black and Hispanic men with early-onset colorectal cancer outpaced other racial groups studied. In addition, Rogers's team examined many other health and social factors, such as smoking. The team observed that although roughly 14% of all U.S. adults are current smokers, 24% of the adult population residing in hotspot counties reported currently smoking and having smoked at least 100 cigarettes in their lifetime. "After identifying these geographic disparities, the focus of our study was to better understand the role of individual and county-level characteristics in explaining regional variations in early-onset colorectal cancer survival among these men," Rogers explained.

Rogers said, "If young men are not already doing so, adults younger than 50 should have conversations with health care providers about early detection screening for colorectal cancer. This is especially the case if they have any symptoms of colorectal cancer, a family history of the disease, or if they live in the 'hotspot' counties we have identified for early-onset colorectal cancer."

Rogers plans to identify early-onset colorectal cancer hotspots in Utah, where his lab is located. The lab studies the health and well-being of underrepresented men through community engagement, research, and education.

Rogers' team is also working to develop a community-based intervention to increase awareness while reducing incidence and death due to early-onset colorectal cancer in Utah and areas of the country where rates are on the rise.

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This study was supported by the National Institutes of Health/National Cancer Institute including P30 CA01420114, K01 CA234319, T32CA190194, and T32HG008962, and by Huntsman Cancer Foundation. The study acknowledges support from key collaborator Justin X. Moore, PhD, of Augusta University in Georgia.

Full study and author list available at https://pubmed.ncbi.nlm.nih.gov/32509399/

Huntsman Cancer Institute (HCI) at the University of Utah is the official cancer center of Utah. The cancer campus includes a state-of-the-art cancer specialty hospital as well as two buildings dedicated to cancer research. HCI treats patients with all forms of cancer and is recognized among the best cancer hospitals in the country by U.S. News and World Report. As the only National Cancer Institute (NCI)-Designated Comprehensive Cancer Center in the Mountain West, HCI serves the largest geographic region in the country, drawing patients from Utah, Nevada, Idaho, Wyoming, and Montana. More genes for inherited cancers have been discovered at HCI than at any other cancer center in the world, including genes responsible for hereditary breast, ovarian, colon, head, and neck cancers, along with melanoma. HCI manages the Utah Population Database, the largest genetic database in the world, with information on more than 11 million people linked to genealogies, health records, and vital statistics. HCI was founded by Jon M. and Karen Huntsman.