Racial disparities in surgical resection and survival among elderly patients with poor prognosis cancer

Abstract

Background: Reports indicate that black patients have lower survival after the diagnosis of a poor prognosis cancer, compared with white patients. We explored the extent to which this disparity is attributable to the underuse of surgery.

Study design: Using the Surveillance, Epidemiology, and End Results program and Medicare database, we identified 57,364 patients, ages 65 years and older, with a new diagnosis of nonmetastatic liver, lung, pancreatic, and esophageal cancer, from 2000 to 2005. We evaluated racial differences in resection rates after adjustment for patient, tumor, and hospital characteristics using hierarchical logistic regression. Cox proportional hazards regression was used to assess racial differences in survival after adjusting for patient, tumor, and hospital characteristics, and receipt of surgery.

Results: Compared with white patients, black patients were less likely to undergo surgery for liver (adjusted odds ratio [aOR] = 0.49; 95% CI, 0.29-0.83), lung (aOR = 0.62; 95% CI, 0.56-0.69), pancreas (aOR = 0.53; 95% CI, 0.41-0.70), and esophagus cancers (aOR = 0.64; 95% CI, 0.42-0.99). Hospitals varied in their surgery rates among patients with potentially resectable disease. However, resection rates were consistently lower for black patients, regardless of the resection rate of the treating hospital. Although there were no racial differences in overall survival with liver and esophageal cancer, black patients experienced poorer survival for lung (adjusted hazard ratio = 1.05; 95% CI, 1.00-1.10) and pancreas cancer (adjusted hazard ratio = 1.15; 95% CI, 1.03-1.30). In both instances, there were no residual racial disparities in overall survival after adjusting for use of surgery.

Conclusions: Black patients are less likely to undergo surgery after diagnosis of a poor prognosis cancer. Our findings suggest that surgery is an important predictor of overall mortality, and that efforts to reduce racial disparities will require stakeholders to gain a better understanding of why elderly black patients are less likely to get to the operating room.

Figure 1

Use of cancer-directed surgery in black and white patients with potentially resectable liver, lung, pancreatic and esophageal cancers, by hospital resection rates. Based on SEER-Medicare 2000-2005, with follow up through 2008. * Complete case analysis of 2,567 liver, 42,991 lung, 5,795 pancreas and 3,611 esophageal cancer patients. Resection rates risk-adjusted for age (65-69, 70-74, 75-79, ≥79 years), gender (male, female), comorbid conditions (0, 1, ≥2), marital status (married, single, other), socioeconomic status (median zip code level income), SEER stage (local, regional) and tumor size (<2.0 cm, 2.0-2.9 cm, 3.0-3.9 cm, 4.0-4.9 cm, ≥5 cm).

Figure 2

Unadjusted survival curves for black and white patients diagnosed with potentially resectable liver, lung, pancreatic and esophageal cancers, by use and non-use of cancer-directed surgery. Based on SEER-Medicare 2000-2005, with follow up through 2008.