Black lives also matter in cancer care
It is not biology, but access to health care that is causing Black Non-Hispanic patients with squamous cell cancer of the head and neck to have lower survival rates
IMAGE: JESSICA MCDERMOTT, MD, AND SANA KARAM, MD, PHD view more
CREDIT: CU CANCER CENTER
Studies have long reported that Black cancer patients have poorer outcomes than their white counterparts. But two University of Colorado Cancer Center researchers decided to investigate the data further and figure out why. What they found was that the outcome disparity was caused not by biology, but simply by differences in access to health care.
The researchers, Jessica McDermott, MD, an assistant professor in the Department of Medical Oncology, and Sana Karam, MD, PhD, an associate professor in the Department of Radiation Oncology, examined Medicare data for individuals suffering squamous cell cancer of the head and neck. All 13,117 patients in this study were diagnosed with their first and only malignant tumor at age 66 or older sometime between 2006 and 2015.
The data confirmed what has been widely reported for years ¬- that the Black head and neck cancer patients had worse outcomes than the white cancer patients.
"But then when we controlled for access to care, those differences suddenly disappeared," says McDermott. "When you closely examine the data, it becomes clear what is going on."
Their findings were published this week in the Journal of the National Comprehensive Cancer Network. The physicians hope their research will catch the attention of those who can help narrow those disparate outcomes.
McDermott and Karam identified two major differences for Black patients: first, they presented at later stages of cancer, and second, they were less likely to receive treatment.
"This is an interesting finding," says McDermott. "A lot of the reasons driving the disparate outcomes came down to socially related things - they were less likely to be married, lived in poor areas, had comorbidities [presence of two or more chronic diseases], were less likely to see a primary care provider in the year leading up to the diagnosis, and were more likely to present in the emergency room."
For most cancers, where and when a patient first presents can make a large difference both in the care received and in the outcome.
"Just a reminder that we are talking about a curable disease, a disease that, if treated properly, can be eradicated with a high degree of certainty," says Karam. "I hope that more targeted interventions can be developed as a result of our findings. The problem lies not so much in biological differences, but access. If Black patients get the treatment, they do just as well."
A teaching and research hospital like the University of Colorado can lead the way in improving the care of underserved communities.
"Like many other tertiary care centers, we have a great number of clinical trials, but not everyone who could benefit from them enjoys access," says Karam. "We need to enhance our ability to deliver more broadly the best and newest trials that can extend life and decrease symptom burden."
Black lives matter
The disparities that Black community members face are gaining national attention after the deaths of George Floyd and other Black men and women. But one area of inequity that has not received as much attention is access to medical care. Last month, dozens of providers gathered at the Anschutz Medical Campus to support a national movement by kneeling with fellow White Coats for Black Lives members.
"Speaking up is an important first step towards change," says Karam. "But it must be accompanied by policy change aimed at expanding access to care. We invest billions in new therapies that might or might not work but devote far less attention to helping our socially challenged patients get through the door, which our study shows does work."
The doctors say that more work is needed to overcome hurdles to health care access.
"We also need to educate the next generation of doctors on showing compassion and sensitivity to issues of race, income, social challenges, addiction, and other access barriers," says Karam.
What the CU Cancer Center is doing to help
Prior to this study's publication, Dr. McDermott was awarded a grant from the CU Cancer Center Office of Community Outreach and Engagement to increase the representation of the Hispanic populations in head and neck cancer clinical trials. Colorado has a large population of Hispanics, which makes that population an easier place to begin making changes.
"Our goal is to use that project to branch out to Hispanics, Blacks, and anyone else with socioeconomic issues that currently compromise their access to care," says McDermott.
The CU Cancer Center will continue studying the health disparities for different types of cancer and investigating strategies for eliminating the barriers faced by those needing care.
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Not all patients are offered the same effective breast cancer treatment
Socioeconomic status and race could play a role in treatment decisions, according to new research.
Breast cancer is one of the most common cancers among women in the U.S. It's also the most costly cancer to treat. Now, Jefferson researchers have shown that although the use of an effective and less expensive treatment is on the rise, some patients, specifically Black women and those without private insurance are offered the beneficial therapy less often. The findings pave the way for reducing healthcare costs and increasing patient satisfaction.
"We have identified patient populations at risk of not receiving a beneficial and more cost-effective therapy," says Dr. Alliric Willis, a surgical oncologist and associate professor of surgery at Sidney Kimmel Medical College (SKMC) - Jefferson Health, who led the study along with his research team from SKMC and the College of Population Health at Thomas Jefferson University.
"This research really illustrates that not all patients are being treated equally," says Dr. Willis, who published the results online September 12, 2020 in the International Journal of Radiation Oncology Biology Physics, also known as the Red Journal.
Standard breast-conserving cancer treatment involves surgery followed by radiation therapy, which helps to lower the risk of cancer recurring in the treated breast. Traditionally, patients receive 25 to 30 daily radiation treatments over five to six weeks. In recent years, however, doctors have begun using an alternative radiation treatment plan known as hypofractionated whole breast radiation (HR).
HR uses a higher radiation dose per treatment than the traditional regimen. The higher dose means patients require about half as many treatment sessions -15 to 16 treatments over three to four weeks - to achieve the same total dose. Compared with traditional radiation therapy, the approach is just as effective at reducing the risk of the cancer returning, more cost-effective and offers patients fewer side effects and better breast restoration outcomes following treatment.
"Despite the fact that both patients and practitioners say they prefer hypofractionated radiation because of its efficacy and better cosmetic outcomes, HR use in the U.S., while increasing, has lagged for particular groups," Dr. Willis says.
To better understand who is at risk of missing out on the valuable therapy, Dr. Willis and colleagues turned to the National Cancer Database. The researchers examined data from nearly 260,000 early-stage breast cancer patients over 40 years old who were diagnosed between 2012 and 2016. All patients studied had received radiation treatment following breast conserving surgery. The researchers looked at demographics, tumor attributes and treatment facility characteristics between patients who received either HR or traditional radiation.
The investigation revealed that HR use increased over the four-year study period, from about a quarter of eligible patients in 2012 to more than two-thirds in 2016. Despite the upward trend, the analysis uncovered marked disparities among those who received HR therapy. Patients who identified as white were most likely to receive HR, whereas HR use was lowest for African Americans, for example.
"When we took all other factors into account, African American women were 15% less likely to be treated with HR than white women," Dr. Willis says. "This demonstrates that even though treatment guidelines do not take race into account, race is a factor in breast cancer treatment."
Socioeconomic status also affected those who received HR therapy. Patients with private insurance were more likely to receive HR than uninsured patients or those on Medicaid, according to the study. In addition, patients who lived in zip codes with the highest income levels were 25% more likely to undergo HR than patients from zip codes in the lowest income category.
Where patients sought care made a difference in their treatment, too. Treatment facilities associated with academic medical centers were twice as likely to use HR as community cancer or integrated network cancer facilities.
"This tells us that there is a need to actively communicate information to healthcare providers about the spectrum of treatment options across all treatment facility types," Dr. Willis says.
Dr. Willis hopes that this research will shine light on treatment inconsistencies and motivate physicians to expand their treatment repertoire.
"Patients should have access to all treatment options no matter their race, socioeconomic background or where they seek care," he says. "Hopefully, our research will help to address gaps in provider education and extend this favorable treatment to all patients."
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Article reference: Steven G. Woodward, MD, Karan Varshney, Pramilla R. Anne, MD, Brandon J. George, PhD, MS, Alliric I. Willis, MD, FACS, "Trends in Utilization of Hypofractionated Whole Breast Radiation in Breast Cancer: An Analysis of the National Cancer Database," The International Journal of Radiation Oncology Biology Physics DOI: 10.1016/j.ijrobp.2020.09.004, 2020.
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