Racial differences in the treatment of early-stage lung cancer

Race and surgical outcomes: it is not all black and white

BACKGROUND

Studies using Medicare data have suggested that African American race is an independent predictor of death after major surgery. We hypothesized that the apparent adverse effect of race on surgical outcomes is due to confounding by comorbidity, not race itself.

METHODS

We identified all non-Hispanic white and African American general surgery, private sector patients included in the National Surgery Quality Improvement Program (NSQIP) Patient Safety in Surgery Study (2001-2004). Patient characteristics, comorbidities, and postoperative outcomes were collected/analyzed using NSQIP methodology. Characteristics between races were compared using Student t and chi(2) tests. Odds ratios (OR) for 30-day morbidity and mortality were calculated using multivariable logistic regression.

RESULTS

We identified 34,141 white and 5068 African American patients. African Americans were younger but more likely to undergo emergency surgery and present with hypertension, dyspnea, diabetes, renal failure, open wounds/infection, or advanced American Society of Anesthesiology class (all P < 0.001). African Americans underwent less complex procedures but had higher unadjusted 30-day morbidity (14.33% vs. 12.35%; P < 0.001) and mortality (2.09% vs. 1.65%; P = 0.02). After controlling for comorbidity, African American race had no independent effect on mortality (OR 0.95, (0.74-1.23)) but was associated with a higher risk of postoperative cardiac arrest (OR 2.49, (1.80-3.45)) and renal insufficiency/failure (OR 1.70 (1.32-2.18)).

CONCLUSION

African American race is associated with greater comorbidity and cardiac/renal complications but is not an independent predictor of perioperative mortality after general surgery. Efforts to improve postoperative outcomes in African Americans should focus on reducing the need for emergency surgery and improving perioperative management of comorbid conditions.

Treatment and survival differences in older Medicare patients with lung cancer as compared with those who are dually eligible for Medicare and Medicaid

PURPOSE

This study compares non-small-cell lung cancer (NSCLC) treatments provided to older patients (age > or = 66 years) who are dually eligible for Medicare and Medicaid with treatments provided to similar patients who are insured by Medicare. We extend the analysis to include a comparison of survival rates between Medicare and dually eligible patients. Dual eligibility is associated with low socioeconomic status. However, Medicaid coverage in addition to Medicare removes many financial barriers to care.

PATIENTS AND METHODS

The sample included 2,626 older patients with local and regional stage NSCLC diagnosed between 1997 and 2000. Four outcomes were studied: the likelihood of receiving resection, chemotherapy, radiation therapy, and survival (perioperative and longer-term). Logistic regression was used to predict the likelihood of treatment, and stratified and multivariate analyses were used to evaluate differences in survival.

RESULTS

Dually eligible patients were half as likely to undergo resection as Medicare patients (P < .001) and were more likely to receive radiation than Medicare patients. Stratified and multivariate analyses showed that surgically treated dually eligible patients had slightly inferior survival as compared with that of Medicare patients. Survival was equivalent among patients who did not undergo resection, regardless of insurance coverage.

CONCLUSION

Older dually eligible patients with NSCLC had a lower likelihood of undergoing resection despite controls for socioeconomic factors and comorbidities. However, if such patients were surgically treated, survival improved substantially, but it remained inferior to the survival of Medicare patients. Additional research is needed to understand why resection rates were substantially lower among dually eligible patients.

Recent trends in Black-White disparities in cancer mortality

Despite decreases in overall cancer death rates across all racial and ethnic groups since the early 1990s, racial disparities in cancer mortality persist. We examined temporal trends in Black-White disparities in cancer mortality from all sites combined, smoking-related cancers (lung and a group including oral cavity, pharynx, larynx, esophagus, pancreas, bladder, and kidney), and sites affected, or potentially affected by screening and treatment (breast, prostate, colon/rectum). Death rates, rate differences, and rate ratios comparing Blacks to Whites from 1975 through 2004 were based on mortality data from the National Center for Health Statistics. The Black-White disparity in overall cancer death rates narrowed from the early 1990s through 2004, especially in men. This reduction was driven predominantly by more rapid decreases in mortality from tobacco-related cancers in Black men than White men. In contrast, racial disparities in mortality from cancers potentially affected by screening and treatment increased over most of the interval since 1975. Coordinated efforts to improve early detection and treatment for all segments of the population are essential to eliminate racial disparities in cancer mortality.

A decade of research on disparities in medicare utilization: lessons for the health and health care of vulnerable men

Medicare research has shown that there are substantial disparities by race and socioeconomic status in use of services. In this article, I review past research and discuss how findings apply specifically to vulnerable men aged 65 years or older. Six lessons from this review are identified and illustrated here. Disparities in certain measures of health are growing; to reverse this trend, substantial efforts are needed, including dissemination of information about disparities as well as testing of hypotheses regarding underlying causes.

Comorbidities and their impact on mortality in HCV and HCV-HIV-coinfected persons on dialysis

AIM

To determine the rates of non-human immuno deficiency virus (HIV)-related comorbidities and their impact on survival in hepatitis C virus (HCV) and HCV-HIV coinfected persons on dialysis.

METHODS

We identified HCV-infected subjects and diagnoses of medical and psychiatric comorbidities in the United States Renal Data System using ICD-9 codes. Logistic regression was used to determine the odds of comorbidities and predictors of mortality.

RESULTS

We identified 5310 HCV-infected and 427 HCVHIV-coinfected subjects. The latter were younger, more likely to be male, black race, and had a lower body mass index. After adjusting for age, race, and sex we found that coronary artery disease (CAD), diabetes mellitus (DM) as primary cause of renal failure and cirrhosis were less frequently diagnosed in the HCVHIV-coinfected subjects, whereas hepatitis B, wasting, drug and alcohol abuse, and dependence were more frequently diagnosed.Increasing age, CAD, stroke, DM, cirrhosis, wasting, cancer,and drug abuse and dependence were associated with higher odds of death in the HCV monoinfected subjects, whereas cirrhosis, wasting, and smoking were the only such factors in the HCV-HIV-coinfected subjects.

CONCLUSIONS

The frequency and patterns of comorbidities and predictors of death differ in HCV-monoinfected and HCVHIV-coinfected persons on dialysis. These differences should be taken into account when designing future interventions.

Outcome of HIV-associated Pneumocystis pneumonia in hospitalized patients from 2000 through 2003

BACKGROUND

Pneumocystis pneumonia (PCP) remains a leading cause of morbidity and mortality in HIV-infected persons. Epidemiology of PCP in the recent era of highly active antiretroviral therapy (HAART) is not well known and the impact of HAART on outcome of PCP has been debated.

AIM

To determine the epidemiology of PCP in HIV-infected patients and examine the impact of HAART on PCP outcome.

METHODS

We performed a retrospective cohort study of 262 patients diagnosed with PCP between January 2000 and December 2003 at a county hospital at an academic medical center. Death while in the hospital was the main outcome measure. Multivariate modeling was performed to determine predictors of mortality.

RESULTS

Overall hospital mortality was 11.6%. Mortality in patients requiring intensive care was 29.0%. The need for mechanical ventilation, development of a pneumothorax, and low serum albumin were independent predictors of increased mortality. One hundred and seven patients received HAART before hospitalization and 16 patients were started on HAART while in the hospital. HAART use either before or during hospitalization was not associated with mortality.

CONCLUSION

Overall hospital mortality and mortality predictors are similar to those reported earlier in the HAART era. PCP diagnoses in HAART users likely represented failing HAART regimens or non-compliance with HAART.

Racial composition of hospitals: effects on surgery for early-stage non-small-cell lung cancer

PURPOSE

Black patients undergo potentially curative surgery for early-stage lung cancer at a lower rate when compared with white patients. Our study examines the relationship between the percentage of black patients treated at a hospital to determine whether it affects the likelihood of obtaining cancer-directed surgery for patients with non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

We examined claims data of Medicare-eligible patients with nonmetastatic NSCLC living in areas monitored by the Surveillance, Epidemiology, and End Results program between 1991 and 2001. Hospitals were categorized by the percentage of black patients seen: or= 30%. Logistic regression with clustering analysis was used to calculate the odds of undergoing surgical resection.

RESULTS

Among 9,688 patients with NSCLC, 59% of white patients were seen at a hospital that had or= 30% black patients. Regression analysis revealed that hospital racial composition of 30% or greater black patients had a significant negative effect on the likelihood of undergoing surgery for all patients (odds ratio [OR] = 0.71; 95% CI, 0.57 to 0.87), with black race (OR = 0.69; 95% CI, 0.56 to 0.85) and being seen at a low-volume hospital (OR = 0.64; 95% CI, 0.0.49 to 0.83) having a significant negative impact on likelihood of undergoing surgery.

CONCLUSION

Our study results indicate that patient and hospital characteristics are significant predictors of undergoing surgery for Medicare beneficiaries with localized lung cancer. Further examination of the role of the patient-, provider-, and hospital-level factors, in association with the decision to pursue surgical treatment of localized lung cancers, is needed.

Cancer survival in New Zealand: ethnic, social and geographical inequalities

This study investigated the combined effects of ethnicity, deprivation and geographical access to health services on the likelihood of survival from a range of common cancers in New Zealand. Individual cancer registry records of 99,062 cases of melanoma, colorectal, lung, breast and prostate cancers diagnosed in the period 1994-2004 were supplemented with small area information on social deprivation and estimates of travel time to the nearest primary care and cancer centre. Logistic regression was used to identify the variables associated with advanced extent of the disease at diagnosis. Adverse influences on survival were investigated using Cox proportional hazards models. Controlling for age and gender, Māori and Pacific peoples' ethnicity was strongly associated with poorer survival, partly because ethnicity was also linked to the likelihood of advanced disease at diagnosis. Living in a deprived area was related to later stage presentation and poorer survival of people with melanoma, but there was no other evidence that living in a deprived area or in a remote location were associated with later stage presentation. Some disease-specific trends in survival were observed. Colorectal and lung cancers were more likely to be fatal for people living in deprived areas, survival from prostate cancer was poor for men living remote from primary care, and people with colorectal, breast and prostate cancers had adverse survival chances if they lived distant from a cancer centre.

Doxorubicin, cardiac risk factors, and cardiac toxicity in elderly patients with diffuse B-cell non-Hodgkin's lymphoma

PURPOSE

Anthracycline-based chemotherapy, which improves survival for patients with non-Hodgkin's lymphoma, is often withheld from elderly patients because of its cardiotoxicity. We studied the cardiac effects of doxorubicin in a population-based sample of older patients with diffuse large B-cell lymphoma (DLBCL).

PATIENTS AND METHODS

Among patients age > or = 65 years diagnosed with DLBCL from 1991 to 2002 in the Surveillance, Epidemiology, and End Results-Medicare database, we developed logistic regression models of the associations of doxorubicin with demographic, clinical, and cardiac variables. We then developed Cox proportional hazards models of the association between doxorubicin and subsequent congestive heart failure (CHF), taking predictors of CHF into account.

RESULTS

Of 9,438 patients with DLBCL, 3,164 (42%) received doxorubicin-based chemotherapy. Any doxorubicin use was associated with a 29% increase in risk of CHF (95% CI, 1.02 to 1.62); CHF risk increased with number of doxorubicin claims, increasing age, prior heart disease, comorbidities, diabetes, and hypertension; hypertension intensified the effect of doxorubicin on risk of CHF (hazard ratio = 1.8; P < .01). In the 8 years after diagnosis, the adjusted CHF-free survival rate was 74% in doxorubicin-treated patients versus 79% in patients not treated with doxorubicin.

CONCLUSION

Among patients receiving chemotherapy for DLBCL, those with prior heart disease were less likely than others to be treated with doxorubicin, and those who received doxorubicin were more likely than others to develop CHF. Various cardiac risk factors increased CHF risk, but only hypertension was synergistic with doxorubicin. Doxorubicin has dramatically improved survival of DLBCL patients; nonetheless, some subgroups may benefit from efforts to reduce doxorubicin-related CHF risk.

Predictors of intravesical therapy for nonmuscle invasive bladder cancer: results from the surveillance, epidemiology and end results program 2003 patterns of care project

PURPOSE

In response to variations in cancer care organizations have developed clinical guidelines. In the case of nonmuscle invasive bladder cancer, also known as superficial bladder cancer, 2 similar sets of guidelines were released in the late 1990s that provide care recommendations. We examined patterns of intravesical therapy use in nonmuscle invasive bladder cancer in 2003 to determine whether disparities remained in the quality of cancer care.

MATERIALS AND METHODS

Data from the SEER (Surveillance, Epidemiology and End Results) Program 2003 Bladder Cancer Patterns of Care project were used. Subjects newly diagnosed with nonmuscle invasive bladder cancer in 2003 were included. Clinical and sociodemographic data were obtained from the SEER Program and a detailed medical record review. Statistical analysis was performed to identify independent predictors of intravesical therapy in the entire cohort and in a subset of patients at high risk.

RESULTS

A total of 685 patients were included in the study, of whom 216 (31.5%) received intravesical therapy. In addition to higher tumor stage and grade, intravesical therapy was independently associated with race/ethnicity and geographic region. Of the subset of 350 patients at high risk 42% received intravesical therapy. Stage, grade, race/ethnicity and geographic region were independently associated with intravesical therapy in this subcohort.

CONCLUSIONS

These data suggest the underuse of intravesical therapy even in patients with high risk nonmuscle invasive bladder cancer as well as disparities in the quality of care. Barriers to using this cancer treatment must be identified, particularly in individuals at higher risk, and providers must become more aware of existing clinical guidelines.

The social determinants of cancer: a challenge for transdisciplinary science

To make further significant advances in cancer control research, a transdisciplinary science approach is needed that integrates the study of the biological nature of cancer and its clinical applications with the behavioral and social influences on cancer. More-effective interventions to reduce the burden of cancer can be developed and implemented by the adoption of a transdisciplinary research framework that takes into account the social determinants of cancer and seeks to discover interactions among social, environmental, behavioral, and biological factors in cancer etiology. This paper addresses two critical issues in the science of team science: (1) a cross-disciplinary, multilevel framework for organizing future research, and (2) a perspective that could aid in the translation and dissemination of cancer research findings in health care and public health practice. This conceptual framework is designed to encourage transdisciplinary research that will integrate social determinants into cancer research. The authors' goal is to promote a more complete understanding of the causes of cancer that will lead to the improved translation and implementation of the results of research.

An exploration of urban and rural differences in lung cancer survival among medicare beneficiaries

OBJECTIVES

We tested the relationship between urban or rural residence as defined by rural-urban commuting area codes and risk of mortality in a sample of Medicare beneficiaries with lung cancer.

METHODS

We used Surveillance, Epidemiology, and End Results data linked with Medicare claims to build proportional hazards models. The models tested hypothesized relationships between individual and community characteristics and overall survival for a cohort of Medicare beneficiaries 65 years and older who were diagnosed with lung cancer between 1995 and 1999 (N=26073).

RESULTS

We found no evidence that lung cancer patients in rural areas have poorer survival than those in urban areas. Rather, individual (Medicaid coverage) and regional (lower census tract-level median income) socioeconomic factors and a smaller supply of subspecialists per 10000 individuals 65 years and older were positively associated with a higher risk of mortality.

CONCLUSIONS

Although urban versus rural residence did not directly influence survival, rural residents were more likely to live in poorer areas with a smaller supply of health care providers. Therefore, we still need to be aware of rural beneficiaries' potential disadvantage when it comes to receiving needed care in a timely fashion.

Underuse of surgical resection for localized, non-small cell lung cancer among whites and African Americans in South Carolina

BACKGROUND

Early studies using Medicare data reported racial disparities in surgical treatment of localized, non-small cell lung cancer. We analyzed the independent effect of race on use of surgical resection in a recent, population-based sample of patients with localized non-small cell lung cancer, controlling for comorbidity and socioeconomic status.

METHODS

All cases of localized non-small cell lung cancer reported to our state Cancer Registry between 1996 and 2002 were identified and linked to the Inpatient/Outpatient Surgery Files and 2000 Census. Comorbidity (Romano-Charlson index) was calculated using administrative data codes. Educational level and income were estimated using census data. Characteristics of white and African American patients were compared using chi(2) tests. Odds ratios of resection and 95% confidence intervals were calculated using logistic regression.

RESULTS

We identified 2,506 white and 550 African American patients. African Americans were more likely to be younger, male, not married, less educated, poor, and uninsured or covered by Medicaid (all p < 0.0001), and to reside in rural communities (p = 0.0005). Use of surgical resection across races was lower than previously reported, and African Americans were significantly less likely to undergo surgery compared with whites (44.7% versus 63.4%; p < 0.0001). Even after controlling for sociodemographics, comorbidity, and tumor factors, the adjusted odds ratio for resection for African Americans was 0.43 (95% confidence interval, 0.34 to 0.55).

CONCLUSIONS

Underuse of surgical resection for localized, non-small cell lung cancer is a persistent problem, particularly among African Americans. Further studies are urgently needed to identify the patient-, physician-, and health system-related factors underlying these observations and optimize resection rates for non-small cell lung cancer.

Temporal trends in the management of potentially resectable lung cancer

BACKGROUND

Standardized, evidence-based guidelines recommend lung resection for patients with stage I or II nonsmall-cell lung cancer (NSCLC), and select patients with stage IIIA disease. We hypothesized that the proportion of patients operated on would increase over time coincident with increasing adherence to practice guidelines and improved patient/provider education over time.

METHODS

This investigation was a cohort study of tumor-registry data linked to Medicare claims.

RESULTS

Between 1992 and 2002, 24,030 patients--mean age 75 +/- 6 years, 55% men--were diagnosed with NSCLC. In each stage, the proportion of patients undergoing resection was lower in 2002 compared with 1992: stage I (68% versus 80%, p < 0.001), II (59% versus 74%, p < 0.001), and IIIA (23% versus 35%, p < 0.001). The mean age and comorbidity index of the cohort was higher in 2002 compared with 1992 (76 versus 74 years, p < 0.001; and 0.47 and 0.82, p < 0.001, respectively). The unadjusted odds of resection decreased by 6% per year (odds ratio 0.94, 99% confidence interval: 0.93 to 0.95), and adjustment for age, comorbidity index, race, and stage resulted in a slightly smaller (4% per year) but significantly decreasing trend in operative management over time (odds ratio 0.96, 99% confidence interval: 0.95 to 0.97).

CONCLUSIONS

Unexpectedly, the use of resection for lung cancer has decreased dramatically over time, and this decline is not fully accounted for by an older cohort with more comorbid conditions. Future investigations should determine whether increasing unmeasured contraindications to resection, barriers to accessing specialty care, an inadequate supply of thoracic surgeons, or bias against operative therapy are responsible.

Black and white chains of risk for hospitalization over 20 years

Drawing from the life course perspective, racial disparities in hospitalization are considered in light of a chain of risk. We ask whether race influences admission to, length of stay in, and mortality following hospitalization. Analyses address these questions with data from a national longitudinal sample of adults to assess racial disparities in the hospitalization experience (n = 6,833). Survey data were merged with hospital records abstracted over 20 years of observation. Multivariate analyses revealed that there were no racial differences in admission, but that black adults generally had longer stays. When isolating each stay prospectively, black adults had longer stays during the first, third, and fourth hospitalizations. Post-hospital mortality after the first stay was also higher for black adults than for their white counterparts, even after controlling for morbidity and status resources. The findings suggest that the racial disparities in hospital length of stay and mortality are explained by the cumulative effects of social and health inequalities over the life course.

A plan for action: key perspectives from the racial/ethnic disparities strategy forum

CONTEXT

Racial and ethnic disparities in health care in the United States have been well documented, with research largely focusing on describing the problem rather than identifying the best practices or proven strategies to address it.

METHODS

In 2006, the Disparities Solutions Center convened a one-and-a-half-day Strategy Forum composed of twenty experts from the fields of racial/ethnic disparities in health care, quality improvement, implementation research, and organizational excellence, with the goal of deciding on innovative action items and adoption strategies to address disparities. The forum used the Results Based Facilitation model, and several key recommendations emerged.

FINDINGS

The forum's participants concluded that to identify and effectively address racial/ethnic disparities in health care, health care organizations should: (1) collect race and ethnicity data on patients or enrollees in a routine and standardized fashion; (2) implement tools to measure and monitor for disparities in care; (3) develop quality improvement strategies to address disparities; (4) secure the support of leadership; (5) use incentives to address disparities; and (6) create a message and communication strategy for these efforts. This article also discusses these recommendations in the context of both current efforts to address racial and ethnic disparities in health care and barriers to progress.

CONCLUSIONS

The Strategy Forum's participants concluded that health care organizations needed a multifaceted plan of action to address racial and ethnic disparities in health care. Although the ideas offered are not necessarily new, the discussion of their practical development and implementation should make them more useful.

Survival of Indigenous and non-Indigenous Queenslanders after a diagnosis of lung cancer: a matched cohort study

OBJECTIVE

To compare survival of Indigenous and non-Indigenous lung cancer patients and to investigate any corresponding differences in stage, treatment and comorbidities.

DESIGN AND SETTING

Cohort study of 158 Indigenous and 152 non-Indigenous patients (frequency-matched on age, sex and rurality) diagnosed with lung cancer between 1996 and 2002 and treated in Queensland public hospitals.

MAIN OUTCOME MEASURES

Survival after diagnosis of lung cancer; effects of stage at diagnosis, treatment, comorbidities and histological subtype on lung cancer-specific survival.

RESULTS

Survival of Indigenous lung cancer patients was significantly lower than that of non-Indigenous patients (median survival, 4.3 v 10.3 months; hazard ratio, 1.48; 95% CI, 1.14-1.92). Of 158 Indigenous patients, 72 (46%) received active treatment with chemotherapy, radiotherapy or surgery compared with 109 (72%) of the 152 non-Indigenous patients, and this treatment disparity remained after adjusting for histological subtype, stage at diagnosis, and comorbidities (adjusted risk ratio, 0.65; 95% CI, 0.53-0.73). The treatment disparity explained most of the survival deficit: the hazard ratio reduced to 1.10 (95% CI, 0.83-1.44) after inclusion of treatment variables in the proportional hazards survival model. The remaining survival deficit was explained by the higher prevalence of comorbidities among Indigenous cancer patients, mainly diabetes.

CONCLUSION

Survival after a diagnosis of lung cancer is worse for Indigenous patients than for non-Indigenous patients, and differences in treatment between the two groups are mainly responsible.

Treatment disparities for disabled medicare beneficiaries with stage I non-small cell lung cancer

Treatment disparities for disabled Medicare beneficiaries with stage I non-small cell lung cancer.

OBJECTIVE

To compare initial treatment and survival of nonelderly adults with and without disabilities newly diagnosed with non-small cell lung cancer.

DESIGN

Retrospective analyses; population-based cohorts.

SETTING

Eleven Surveillance, Epidemiology, and End Results cancer registries.

PARTICIPANTS

Persons with disability Medicare entitlement (n=1016) and nondisabled persons (n=8425) ages 21 to 64 years when diagnosed with stage I, pathologically confirmed, first primary non-small cell lung cancer between January 1, 1988, and December 31, 1999.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Initial cancer treatments (surgery, radiotherapy), survival (through December 31, 2001). Multivariable logistic regression and Cox proportional hazards regression estimated adjusted associations of disability status with treatments and survival.

RESULTS

Persons with disabilities were much more likely to be male, non-Hispanic black, and not currently married. Although 82.2% of nondisabled persons had surgery, 68.5% of disabled persons received operations. Adjusted relative risks (RRs) of receiving surgery were especially low for persons with respiratory disabilities (adjusted RR=.76; 95% confidence interval [CI], .67-.85), nervous system conditions (adjusted RR=.86; 95% CI, .76-.98), and mental health and/or mental retardation disorders (adjusted RR=.92; 95% CI, .86-.99). Persons with disabilities had significantly higher cancer-specific mortality rates (hazard ratio [HR]=1.37; 95% CI, 1.24-1.51) than persons without disabilities. Observed differences in cancer mortality persisted after adjusting for demographic and tumor characteristics (adjusted relative HR=1.23; 95% CI, 1.10-1.39). Further adjustment for surgery use eliminated statistically significant differences in cancer mortality between persons with and without disabilities across disabling conditions.

CONCLUSIONS

Persons with disabilities were much less likely than nondisabled Medicare beneficiaries to receive surgery; statistically significant cancer-specific mortality differences disappeared after accounting for these treatment differences. Future research must explore reasons for these findings and whether survival of disabled Medicare beneficiaries with early-stage, non-small cell lung cancer could improve if surgical treatment disparities were eliminated.

An overview of methods for monitoring social disparities in cancer with an example using trends in lung cancer incidence by area-socioeconomic position and race-ethnicity, 1992-2004

The authors provide an overview of methods for summarizing social disparities in health using the example of lung cancer. They apply four measures of relative disparity and three measures of absolute disparity to trends in US lung cancer incidence by area-socioeconomic position and race-ethnicity from 1992 to 2004. Among females, measures of absolute and relative disparity suggested that area-socioeconomic and race-ethnic disparities increased over these 12 years but differed widely with respect to the magnitude of the change. Among males, the authors found substantial disagreement among summary measures of relative disparity with respect to the magnitude and the direction of change in disparities. Among area-socioeconomic groups, the index of disparity increased by 47% and the relative concentration index decreased by 116%, while for race-ethnicity the index of disparity increased by 36% and the Theil index increased by 13%. The choice of a summary measure of disparity may affect the interpretation of changes in health disparities. Important issues to consider are the reference point from which differences are measured, whether to measure disparity on the absolute or relative scale, and whether to weight disparity measures by population size. A suite of indicators is needed to provide a clear picture of health disparity change.

Racial disparities in cancer therapy: did the gap narrow between 1992 and 2002?

BACKGROUND

The purpose of this study was to determine whether racial disparities in cancer therapy had diminished since the time they were initially documented in the early 1990s.

METHODS

The authors identified a cohort of patients in the SEER-Medicare linked database who were ages 66 to 85 years and who had a primary diagnosis of colorectal, breast, lung, or prostate cancer during 1992 through 2002. The authors identified 7 stage-specific processes of cancer therapy by using Medicare claims. Candidate covariates in multivariate logistic regression included year, clinical, and sociodemographic characteristics, and physician access before cancer diagnosis.

RESULTS

During the full study period, black patients were significantly less likely than white patients to receive therapy for cancers of the lung (surgical resection of early stage, 64.0% vs 78.5% for blacks and whites, respectively), breast (radiation after lumpectomy, 77.8% vs 85.8%), colon (adjuvant therapy for stage III, 52.1% vs 64.1%), and prostate (definitive therapy for early stage, 72.4% vs 77.2%, respectively). For both black and white patients, there was little or no improvement in the proportion of patients receiving therapy for most cancer therapies studied, and there was no decrease in the magnitude of any of these racial disparities between 1992 and 2002. Racial disparities persisted even after restricting the analysis to patients who had physician access before their diagnosis.

CONCLUSIONS

There has been little improvement in either the overall proportion of Medicare beneficiaries receiving cancer therapies or the magnitude of racial disparity. Efforts in the last decade to mitigate cancer therapy disparities appear to have been unsuccessful.

Impact of activated vitamin D and race on survival among hemodialysis patients

Contrary to most examples of disparities in health outcomes, black patients have improved survival compared with white patients after initiating hemodialysis. Understanding potential explanations for this observation may have important clinical implications for minorities in general. This study tested the hypothesis that greater use of activated vitamin D therapy accounts for the survival advantage observed in black and Hispanic patients on hemodialysis. In a prospective cohort of non-Hispanic white (n = 5110), Hispanic white (n = 979), and black (n = 3214) incident hemodialysis patients, higher parathyroid hormone levels at baseline were the primary determinant of prescribing activated vitamin D therapy. Median parathyroid hormone was highest among black patients, who were most likely to receive activated vitamin D and at the highest dosage. One-year mortality was lower in black and Hispanic patients compared with white patients (16 and 16 versus 23%; P < 0.01), but there was significant interaction between race and ethnicity, activated vitamin D therapy, and survival. In multivariable analyses of patients treated with activated vitamin D, black patients had 16% lower mortality compared with white patients, but the difference was lost when adjusted for vitamin D dosage. In contrast, untreated black patients had 35% higher mortality compared with untreated white patients, an association that persisted in several sensitivity analyses. In conclusion, therapy with activated vitamin D may be one potential explanation for the racial differences in survival among hemodialysis patients. Further studies should determine whether treatment differences based on biologic differences contribute to disparities in other conditions.

Variability in chemotherapy delivery for elderly women with advanced stage ovarian cancer and its impact on survival

Given the survival benefits of adjuvant chemotherapy for advanced ovarian cancer (OC), we examined the associations of survival with the time interval from debulking surgery to initiation of chemotherapy and with the duration of chemotherapy. Among patients > or =65 years with stages III/IV OC diagnosed between 1991 and 2002 in the Surveillance, Epidemiology, and End Results-Medicare database, we developed regression models of predictors of the time interval from surgery to initiation of chemotherapy and of the total duration of chemotherapy. Survival was examined with Cox proportional hazards models. Among 2558 patients, 1712 (67%) initiated chemotherapy within 6 weeks of debulking surgery, while 846 (33%) began treatment >6 weeks. Older age, black race, being unmarried, and increased comorbidities were associated with delayed initiation of chemotherapy. Delay of chemotherapy was associated with an increase in mortality (hazard ratio (HR)=1.11; 95% CI, 1.0-1.2). Among 1932 patients in the duration of treatment analysis, the 1218 (63%) treated for 3-7 months had better survival than the 714 (37%) treated for < or =3 months (HR=0.84; 95% CI, 0.75-0.94). This analysis represents one of the few studies describing treatment delivery and outcome in women with advanced OC. Delayed initiation and early discontinuation of chemotherapy were common and associated with increased mortality.

Barriers to recruiting underrepresented populations to cancer clinical trials: a systematic review

Racial and ethnic minorities, older adults, rural residents, and individuals of low socioeconomic status are underrepresented among participants in cancer-related trials. The authors conducted a systematic review to determine the barriers to participation of underrepresented populations in cancer-related trials. Their search included English-language publications that reported original data on the recruitment of underrepresented groups to cancer treatment or prevention trials between 1966 and December 2005 in multiple electronic databases. They also hand-searched titles in 34 journals from January 2003 to December 2005 and they examined reference lists for eligible articles. Titles and abstracts were reviewed to identify relevant studies. Data on barriers to participation were synthesized both qualitatively and based on statistically significant associations with trial enrollment. Of 5257 studies that were cited, 65 studies were eligible for inclusion in the current analysis, including 46 studies on recruitment into cancer therapeutic trials, 15 studies on recruitment into prevention trials, and 4 studies on recruitment into both prevention and treatment trials. Numerous factors were reported as barriers to participation in cancer-related trials. However, only 20 of the studies reported statistically significant associations between hypothesized barriers and enrollment. The available evidence had limitations in quality regarding representativeness, justification of study methods, the reliability and validity of data-collection methods, potential for bias, and data analysis. The results indicated that underrepresented populations face numerous barriers to participation in cancer-related trials. The current systematic review highlighting the literature on recruitment of underrepresented populations to cancer trials and may be used as the evidence base toward developing an agenda for etiologic and intervention research to reduce the disparities in participation in cancer-related trials.

The contributing role of health-care communication to health disparities for minority patients with asthma

Asthma is a common, chronic illness with substantial morbidity, especially for racial and ethnic minorities in the United States. The care of the patient with asthma is complex and depends ideally on excellent communication between patients and health-care providers. Communication is essential for the patient to communicate the severity of his or her illness, as well as for the health-care provider to instruct patients on pharmacologic and nonpharmacologic care. This article describes evidence for poor provider/patient communication as a contributor to health-care disparities for minority patients with asthma. Communication problems stem from issues with patients, health-care providers, and health-care systems. It is likely that asthma disparities can be improved, in part, by improving patient/provider communication. While much is known presently about the problem of patient/provider communication in asthma, there is a need to improve and extend the evidence base on the role of effective communication of asthma care and the links to outcomes for minorities. Additional studies are needed that document the extent to which problems with doctor/patient communication lead to inadequate care and poor outcomes for minorities with asthma, as well as mechanisms by which these disparities occur.

Mortality from leading causes by education and race in the United States, 2001

BACKGROUND

Low educational attainment is a marker of socioeconomic status that correlates strongly with higher death rates from many conditions. No previous studies have analyzed national data to measure the number of deaths associated with lower education among working-aged adults (25-64 years) by race or ethnicity. Furthermore, no previous studies have examined comprehensively the relationship of education to cause-specific and all-cause mortality in the three largest racial or ethnic groups in the United States using national data.

METHODS

Age-standardized, race/ethnicity-specific death rates from all causes and the 15 leading causes were measured among men and women aged 25-64 years by level of education based on U.S. national mortality data in 2001. The total number of deaths that potentially could be avoided among people aged 25-64 years was estimated by applying the mortality rates among college graduates (within each 5-year category of age, gender, and race/ethnicity) to each of the less-educated subpopulations. All analyses were performed in 2007.

RESULTS

Nearly half (48%) of all deaths among men aged 25-64 years (white, black, and Hispanic), and 38% of all deaths in women would not have occurred in this age range if all segments of the population experienced the death rates of college graduates. Black men and women had the highest death rates from all causes combined and from many specific causes at nearly all levels of education, and the largest average life years lost before age 65 years. However, the total number of deaths associated with low education status was not confined to any single racial group. About 161,280 deaths in whites, 40,840 deaths in blacks, and 13,162 deaths in Hispanics in this age range were associated with educational disparity.

CONCLUSIONS

Potentially avoidable factors associated with lower educational status account for almost half of all deaths among working-aged adults in the U.S.; these deaths are not confined to any single racial or ethnic group. These findings highlight the need for greater attention to social determinants of health.

Racial disparities in utilization of liver transplantation for hepatocellular carcinoma in the United States, 1998-2002

BACKGROUND AND AIMS

The extent of use of liver transplantation on a population scale to treat hepatocellular carcinoma (HCC) in the United States is unknown. We assessed recent predictors of use of liver transplantation and its effect on survival for those with nonmetastatic HCC.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) program is a collection of population-based cancer registries. We identified adults registered in SEER with HCC between 1998 and 2002. We examined determinants for receipt of a liver transplant in univariate and multivariable analyses. Kaplan-Meier survival curves were constructed for those who received and did not receive a transplant for HCC.

RESULTS

We identified 1,156 adults with small (5 cm or less) nonmetastatic HCC. Approximately 45% were white, 29% Asian, 17% Hispanic, and 9% African American. Only 21% received a transplant. More recent year of diagnosis, younger age, being married, white race, and smaller tumor size each predicted receipt of transplant. African Americans and Asians were about half as likely to receive a transplant as compared with white patients (odds ratio [OR] 0.43, 95% confidence interval [CI] 0.21-0.90 for African Americans, and 0.57, 95% CI 0.36-0.89 for Asians). Hispanics trended in the same direction, but this was not statistically significant (OR 0.66, 95% CI 0.39-1.12). Those who underwent liver transplantation for localized HCC had 3- and 5-yr survivals of 81% and 75%, respectively.

CONCLUSIONS

Only one-fifth of those with small, nonmetastatic HCC received liver transplantation. Transplanted patients have long-term survival similar to that of the best single-institution studies. However, marked racial variations were seen, with African Americans and Asians significantly less likely to receive a transplant after controlling for other variables.

Beyond the Traditional Prognostic Indicators: The Impact of Primary Care Utilization on Cancer Survival

Purpose

To our knowledge to date, the effect of primary care utilization on health outcomes in cancer patients has not been described. The objective of this study was to investigate the impact of primary care utilization within 6 months of cancer diagnosis on survival in patients with lung cancer.

Patients and Methods

We used electronic medical record data (1997 to 2005) to identify male veterans with incident lung cancers (N = 323). Primary care utilization was assessed in the 6 months after cancer diagnosis. Patients were observed from cancer diagnosis to death or to last date of health care utilization (ie, censoring date). Univariate and multivariate Cox proportional hazards models tested whether primary care utilization was associated with improved survival. Multivariate analyses adjusted for demographic and clinical characteristics.

Results

During an average follow-up of 16.6 months, 259 patients died. In multivariate analysis, the risk of death was 36% (hazard ratio [HR], 0.64; 95% CI, 0.45 to 0.90), 56% (HR, 0.44; 95% CI, 0.29 to 0.65), and 57% (HR, 0.43; 05% CI, 0.29 to 0.64) lower for patients who had one, two, or at least three primary care visits, respectively, in the first 6 months after cancer diagnosis as compared with those without primary care utilization. The median survival duration (P < .0001, log-rank test) was 3.68, 7.52, 13.88, and 13.75 months for patients with no, one, two, or at least three primary care visits, respectively.

Conclusion

Primary care utilization in the early phase of cancer treatment has a marked effect that results in a reduced mortality risk in patients with incident lung cancer. Additional research is required to determine how and why primary care utilization is an important prognostic indicator of prolonged survival in patients with lung cancer.

Racial differences in waiting list outcomes in chronic obstructive pulmonary disease

RATIONALE

Blacks with chronic illness have poorer outcomes than whites in the United States. The health outcomes of minorities with chronic obstructive pulmonary disease (COPD) on the lung transplant waiting list have not been studied.

OBJECTIVES

To compare outcomes of black and white patients with COPD after listing for lung transplantation in the United States.

METHODS

Retrospective cohort study of all 280 non-Hispanic black and 5,272 non-Hispanic white adults 40 years and older with COPD listed for lung transplantation in the United States between 1995 and 2004.

MEASUREMENTS AND MAIN RESULTS

Blacks with COPD were more likely to have pulmonary hypertension, obesity, and diabetes; to lack private health insurance; and to live in poorer neighborhoods than whites. Blacks were less likely to undergo transplantation after listing compared with whites, despite adjustment for age, lung function, pulmonary hypertension, cardiovascular risk factors, insurance coverage, and poverty level (adjusted hazard ratio, 0.83; 95% confidence interval, 0.70-0.98; P = 0.03). This was accompanied by a greater risk of dying or being removed from the list among blacks (unadjusted hazard ratio, 1.31; 95% confidence interval, 1.05-1.63; P = 0.02).

CONCLUSIONS

After listing for lung transplantation, black patients with COPD were less likely to undergo transplantation and more likely to die or be removed from the list compared with white patients. Unequal access to care may have contributed to these differences.

Disentangling the effects of race on breast cancer treatment

BACKGROUND

African Americans (AA) have higher mortality from breast cancer compared with white Americans (WA). Studies using population-based cancer registries have attributed this to disparities in treatment after normalizing the AA and WA populations for differences in disease stage. However, those studies were hampered by lack of comorbidity data and limited information about systemic treatments. The objective of the current study was to investigate racial disparities in breast cancer treatment by conducting a comprehensive medical records review of women who were diagnosed with breast cancer at the Karmanos Cancer Institute (KCI) in Detroit, Michigan.

METHODS

The study cohort consisted of 651 women who were diagnosed with primary breast cancer between 1990 and 1996 at KCI. Multivariable logistic regression analysis controlling for sociodemographic factors, tumor characteristics, comorbidities, and health insurance status was used to assess whether there were differences between WA and AA in the receipt of breast-conserving surgery (BCS), radiation, tamoxifen, and chemotherapy.

RESULTS

There was no significant difference between WA and AA in the receipt of BCS versus mastectomy. Patients with local-stage disease who were enrolled in government insurance plans underwent mastectomy more often (vs BCS plus radiation) compared with patients who were enrolled in nongovernment plans. The rates of receipt of tamoxifen and chemotherapy were similar for local-stage WA and local-stage AA. However, WA were more likely to receive tamoxifen and/or chemotherapy for regional-stage disease. Married women with regional disease were more likely to receive chemotherapy than nonmarried women.

CONCLUSIONS

The results from this study may be used to target educational interventions to improve the use of adjuvant therapies among AA women who have regional-stage disease.

African American bereaved family members' perceptions of the quality of hospice care: lessened disparities, but opportunities to improve remain

Previous research has documented striking disparities in bereaved family members' perceptions of the quality of end-of-life care between African American and white decedents. Using data from the 2005 repository of the Family Evaluation of Hospice Care survey, we examined whether this disparity in quality of end-of-life care persists once an African American is enrolled in hospice. Of the 121,817 decedents whose proxies were surveyed, 4,095 were non-Hispanic black (African American), and 97,525 were non-Hispanic white. There were no statistically significant differences with regard to decedents' gender. Length of stay on hospice was similar across racial groups. Although previous research has demonstrated striking disparities in the perceived quality of end-of-life care, we found that there were either no differences (quality ratings scores) or less of a disparity in perceptions of concerns with the quality of end-of-life care when compared to the results of a previously reported national mortality follow-back survey, suggesting that though disparities in perceptions of care at end of life persist, on hospice they improve to some degree.

[Evaluation of clinical practice in pulmonary oncology: a review of the literature]

INTRODUCTION

Evaluation of clinical practice in pulmonary oncology aims to improve both the quality of care and the control of costs.

REVIEW OF THE LITERATURE

A Medline search of the literature allowed analysis of the published studies of the evaluation of clinical practice. They showed that though 82-95% of patients with small cell bronchial carcinoma were treated with a combination of etoposide and cisplatin, less than half of the patients with non-small cell cancer received treatment.

VIEWPOINT

Various factors such as age, comorbidity, race, socio-economic status and gender affect the treatment decisions. There is also a discrepancy between the trial data and clinical practice that could be explained by two factors. On one hand advances are not always adopted by doctors and on the other hand the patient populations treated may sometimes be different from those in the trials.

CONCLUSION

Though the number of published studies is still low an increase is to be expected on account of the publication of new regulations concerning the evaluation of clinical practice and the appropriate use of drugs.

Longitudinal, population-based study of racial/ethnic differences in colorectal cancer survival: impact of neighborhood socioeconomic status, treatment and comorbidity

Background

Colorectal cancer, if detected early, has greater than 90% 5-year survival. However, survival has been shown to vary across racial/ethnic groups in the United States, despite the availability of early detection methods.

Methods

This study evaluated the joint effects of sociodemographic factors, tumor characteristics, census-based socioeconomic status (SES), treatment, and comorbidities on survival after colorectal cancer among and within racial/ethnic groups, using the SEER-Medicare database for patients diagnosed in 1992–1996, and followed through 1999.

Results

Unadjusted colorectal cancer-specific mortality rates were higher among Blacks and Hispanic males than whites (relative rates (95% confidence intervals) = 1.34 (1.26–1.42) and 1.16 (1.04–1.29), respectively), and lower among Japanese (0.78 (0.70–0.88)). These patterns were evident for all-cause mortality, although the magnitude of the disparity was larger for colorectal cancer mortality. Adjustment for stage accounted for the higher rate among Hispanic males and most of the lower rate among Japanese. Among Blacks, stage and SES accounted for about half of the higher rate relative to Whites, and within stage III colon and stages II/III rectal cancer, SES completely accounted for the small differentials in survival between Blacks and Whites. Comorbidity did not appear to explain the Black-White differentials in colorectal-specific nor all-cause mortality, beyond stage, and treatment (surgery, radiation, chemotherapy) explained a very small proportion of the Black-White difference. The fully-adjusted relative mortality rates comparing Blacks to Whites was 1.14 (1.09–1.20) for all-cause mortality and 1.21 (1.14–1.29) for colorectal cancer specific mortality. The sociodemographic, tumor, and treatment characteristics also had different impacts on mortality within racial/ethnic groups.

Conclusion

In this comprehensive analysis, race/ethnic-specific models revealed differential effects of covariates on survival after colorectal cancer within each group, suggesting that different strategies may be necessary to improve survival in each group. Among Blacks, half of the differential in survival after colorectal cancer was primarily attributable to stage and SES, but differences in survival between Blacks and Whites remain unexplained with the data available in this comprehensive, population-based, analysis.

Impact of hepatitis C virus infection and other comorbidities on survival in patients on dialysis

The impact of hepatitis C virus (HCV) and other comorbid conditions upon survival is not well quantified in patients on dialysis. We identified HCV-infected and uninfected persons in the USRDS using claims data in 1997-1998 and followed until September 22, 2002 or death. We used Gray's time-varying coefficients model to examine factors associated with survival. Subjects with a renal transplant were excluded. A total of 5737 HCV-infected and 11 228 HCV-uninfected persons were identified. HCV-infected subjects were younger (mean age 57.8 vs 65.3 years), more likely to be male (57.6%vs 49.6%) and black (54.0%vs 36.4%). They were more likely to have a diagnosis of drug (16.5%vs 4.6%) and alcohol use (14.0%vs 3.1%), and to be human immunodeficiency virus (HIV) co-infected (7.4%vs 1.8%) (all comparisons, P < 0.0005). In an adjusted Gray's time-varying coefficient model, HCV was associated with an increased risk of mortality (P < 0.0005). The hazards were highest at the time of HCV diagnosis and decreased to a stable level 2 years after diagnosis. Other factors associated with increased risk of mortality were (P < 0.0005 unless stated) HIV coinfection; diagnosis of drug use (P = 0.001); coronary artery disease (P = 0.006); stroke; diabetes as the primary cause for renal failure; peripheral vascular disease; depression and presence of anaemia. HCV was associated with higher risk of death in patients on dialysis, even after adjusting for concurrent comorbidities. The risk was highest at the time of HCV diagnosis and stabilized over time. Clinical trials of HCV screening and treatment to reduce mortality in this population are warranted.

International comparisons of survival from lung cancer: pitfalls and warnings

Population-based survival data can provide valuable comparative data on outcome but should be interpreted with caution. Differences in data collection and analysis, patient and tumor characteristics and treatment options can have an impact on reported results. Ideally, data from the whole population, including clinical-only diagnoses, should be reported and the methods of case identification described. The relative survival rates should preferably be given. Data on patient characteristics such as age, sex, ethnicity and socioeconomic deprivation should be described, together with tumor details such as pathology and clinical stage. Whenever possible, details on the use of treatments should be reported.

Disparities in treatment and outcome for renal cell cancer among older black and white patients

PURPOSE

Black patients with renal cell cancer have shorter survival compared with their white counterparts, but the causes for this disparity are unclear. To elucidate reasons for this inequality, we examined differences in treatment and survival between black and white patients.

PATIENTS AND METHODS

A retrospective cohort study was conducted using data from the linked Surveillance, Epidemiology and End Results (SEER) cancer registry and Medicare databases. Participants included 964 black and 10,482 white patients age >or= 65 years who were enrolled into Medicare and diagnosed with renal cell cancer between 1986 and 1999. Information on surgical treatment was ascertained from both databases, whereas data regarding coexisting illness and survival was obtained from the Medicare database.

RESULTS

The percentage of black patients receiving nephrectomy treatment was significantly lower compared with whites (61.2% v 70.4%; P < .0001). After adjustment for age, sex, median income, cancer stage, tumor size, and comorbidity index, blacks were less likely to undergo nephrectomy treatment compared with whites (risk ratio = 0.93; 95% CI, 0.90 to 0.96). Overall survival was worse for blacks than whites even after adjustment for demographic and cancer prognostic factors (hazard ratio [HR] = 1.16; 95% CI, 1.07 to 1.25); however, additional adjustment for comorbidity index and nephrectomy treatment reduced the disparity substantially (HR = 1.00; 95% CI, 0.93 to 1.09).

CONCLUSION

This study indicates that the lower survival rate among blacks compared with whites with renal cell cancer can be explained largely by the increased number of comorbid health conditions and the lower rate of surgical treatment among black patients.

Impact of socioeconomic status and distance from treatment center on survival in patients receiving remission induction therapy for newly diagnosed acute myeloid leukemia

BACKGROUND

While socioeconomic status (SES) and the distance patients travel to a treatment center (DTC) impact survival of certain solid tumors, little is known of their influence in acute myeloid leukemia (AML).

METHODS

We retrospectively reviewed patients receiving remission induction therapy for AML at the Cleveland Clinic between January 1997 and December 2005. Demographic data were obtained from medical records. Income and DTC were determined using online databases. Known prognostic factors (age, WBC count at diagnosis, cytogenetics, AML etiology) were collected and controlled for in Cox proportional hazards analysis.

RESULTS

Induction chemotherapy was administered to 281 patients; 91% were Caucasian (C), 8% were African American (AA), and 1% were neither (non-AA non-C). The median DTC was 24 miles (range, 0.9-2058), and median annual household income was USD 38,972 (range, USD17,496-143,220). With a median follow up of 22.6 months, the median overall survival (OS) was 11.3 months. In multivariable analyses, age >or=60 years, unfavorable cytogenetics, initial WBC count and secondary AML significantly influenced survival (p<0.001, p<0.001, p=0.035, and p=0.010, respectively). OS was similar for AAs and non-AA non-Cs compared to Cs (HR=1.12, 95% CI=.61-2.07, p=.71, and HR=0.87, CI=0.21-3.62, p=.84, respectively). Neither DTC (HR=1.00, 95%CI=0.98-1.01, p=.96 per 20 mile increment) nor SES (HR=1.02, 95%CI=0.92-1.13, p=.77 per USD10,000 annual income increase) had an impact on OS.

CONCLUSION

Unlike with many solid tumors, SES and DTC are not predictive of outcome in AML patients.