Racial differences in the outcome of patients with colorectal carcinoma

Colorectal cancer care continuum: Navigating screening, treatment, and outcomes disparities

This review investigates the disparities in colorectal cancer screening, treatment, and outcomes among different racial, ethnic, socioeconomic, and geographic groups. Although there has been progress, notable disparities continue to exist as a result of socioeconomic status, access to healthcare, and systemic prejudices. Approaches to tackle these challenges involve expanding screening access, enhancing healthcare utilization, addressing socioeconomic obstacles, ensuring fair treatment, and boosting representation in research.

Germline cis variant determines epigenetic regulation of the anti-cancer drug metabolism gene dihydropyrimidine dehydrogenase (DPYD)

Enhancers are critical for regulating tissue-specific gene expression, and genetic variants within enhancer regions have been suggested to contribute to various cancer-related processes, including therapeutic resistance. However, the precise mechanisms remain elusive. Using a well-defined drug-gene pair, we identified an enhancer region for dihydropyrimidine dehydrogenase (DPD, DPYD gene) expression that is relevant to the metabolism of the anti-cancer drug 5-fluorouracil (5-FU). Using reporter systems, CRISPR genome-edited cell models, and human liver specimens, we demonstrated in vitro and vivo that genotype status for the common germline variant (rs4294451; 27% global minor allele frequency) located within this novel enhancer controls DPYD transcription and alters resistance to 5-FU. The variant genotype increases recruitment of the transcription factor CEBPB to the enhancer and alters the level of direct interactions between the enhancer and DPYD promoter. Our data provide insight into the regulatory mechanisms controlling sensitivity and resistance to 5-FU.

Racial Disparities in Receipt of Guideline-Concordant Care for Early-Onset Colorectal Cancer in the United States

PURPOSE

Young individuals racialized as Black are more likely to die after a colorectal cancer (CRC) diagnosis than individuals racialized as White in the United States. This study examined racial disparities in receipt of timely and guideline-concordant care among individuals racialized as Black and White with early-onset CRC.

METHODS

Individuals age 18-49 years racialized as non-Hispanic Black and White (self-identified) and newly diagnosed with CRC during 2004-2019 were selected from the National Cancer Database. Patients who received recommended care (staging, surgery, lymph node evaluation, chemotherapy, and radiotherapy) were considered to have received guideline-concordant care. Odds ratios (ORs) were adjusted for age and sex. The decomposition method was used to estimate the relative contribution of demographic characteristics (age and sex), comorbidities, health insurance, and facility type to the racial disparity in receipt of guideline-concordant care. The product-limit method was used to evaluate differences in time to treatment between patients racialized as Black and White.

RESULTS

Of the 84,882 patients with colon cancer and 62,573 patients with rectal cancer, 20.8% and 14.5% were racialized as Black, respectively. Individuals racialized as Black were more likely to not receive guideline-concordant care for colon (adjusted OR [aOR], 1.18 [95% CI, 1.14 to 1.22]) and rectal (aOR, 1.27 [95% CI, 1.21 to 1.33]) cancers. Health insurance explained 28.2% and 21.6% of the disparity among patients with colon and rectal cancer, respectively. Individuals racialized as Black had increased time to adjuvant chemotherapy for colon cancer (hazard ratio [HR], 1.28 [95% CI, 1.24 to 1.32]) and neoadjuvant chemoradiation for rectal cancer (HR, 1.42 [95% CI, 1.37 to 1.47]) compared with individuals racialized as White.

CONCLUSION

Patients with early-onset CRC racialized as Black receive worse and less timely care than individuals racialized as White. Health insurance, a modifiable factor, was the largest contributor to racial disparities in receipt of guideline-concordant care in this study.

Germline cis variant determines epigenetic regulation of the anti-cancer drug metabolism gene dihydropyrimidine dehydrogenase (DPYD)

Enhancers are critical for regulating tissue-specific gene expression, and genetic variants within enhancer regions have been suggested to contribute to various cancer-related processes, including therapeutic resistance. However, the precise mechanisms remain elusive. Using a well-defined drug-gene pair, we identified an enhancer region for dihydropyrimidine dehydrogenase (DPD, DPYD gene) expression that is relevant to the metabolism of the anti-cancer drug 5-fluorouracil (5-FU). Using reporter systems, CRISPR genome edited cell models, and human liver specimens, we demonstrated in vitro and vivo that genotype status for the common germline variant (rs4294451; 27% global minor allele frequency) located within this novel enhancer controls DPYD transcription and alters resistance to 5-FU. The variant genotype increases recruitment of the transcription factor CEBPB to the enhancer and alters the level of direct interactions between the enhancer and DPYD promoter. Our data provide insight into the regulatory mechanisms controlling sensitivity and resistance to 5-FU.

Colon cancer epidemiology, race and socioeconomic status: Comparing trends in counties served by an urban hospital in Newark, NJ with overall NJ-state and nation-wide patterns

PURPOSE

Disparities in colorectal cancer (CRC) trends are linked with socioeconomic status (SES) and race. To better understand the colon cancer trends at our medical center, this study characterizes the racial and socioeconomic profile of the population served by our center to identify modifiable risk factors amenable to interventions.

METHODS

Colon cancer data from our center as well as New Jersey (NJ) and United States (US) were obtained from National Cancer Database. Demographic data on race and SES for NJ counties were obtained from public databases that sourced data from the American Community Survey and the US census. We compared the odds of being diagnosed with early-onset and late-stage colon cancer (III or IV), respectively in NJ and US, across different racial groups. We also quantified the association between Social Vulnerability Index (SVI) and age-adjusted CRC mortality in NJ counties, with and without accounting for the racial composition of each county.

RESULTS

In 2015, our center recorded higher proportions of late-stage and early-onset colon cancer diagnoses compared to all hospitals in NJ and US. Trends for stage and patient age at diagnosis of colon cancer for NJ and the US (2010-2019) showed that Black, Hispanic, and Asian/Pacific Islander individuals had greater odds of being diagnosed with early-onset (age<50) and late-stage colon cancer (Stage III/IV) when compared to White population. NJ counties served by our center showed an overrepresentation of either Black or Hispanic-Latino populations and reported significant disadvantage in SES. For NJ counties, each 25 percentile increase in social vulnerability was associated with 1.04 times the rate of age-adjusted colorectal cancer death (95 % CI: 1.00-1.07).

CONCLUSION

Public data on race and SES of the target population can help identify areas of social disparities at the county-level to guide targeted interventions such as improving healthcare access and screening rates.

Exploring equity in cancer treatment, survivorship, and service utilisation for culturally and linguistically diverse migrant populations living in Queensland, Australia: a retrospective cohort study

BACKGROUND

There is strong international evidence documenting inequities in cancer care for migrant populations. In Australia, there is limited information regarding cancer equity for Culturally and Linguistically Diverse (CALD) migrant populations, defined in this study as migrants born in a country or region where English is not the primary language. This study sought to quantify and compare cancer treatment, survivorship, and service utilisation measures between CALD migrant and Australian born cancer populations.

METHODS

A retrospective cohort study was conducted utilising electronic medical records at a major, tertiary hospital. Inpatient and outpatient encounters were assessed for all individuals diagnosed with a solid tumour malignancy in the year 2016 and followed for a total of five years. Individuals were screened for inclusion in the CALD migrant or Australian born cohort. Bivariate analysis and multivariate logistic regression were used to compare treatment, survivorship, and service utilisation measures. Sociodemographic measures included age, sex, post code, employment, region of birth and marital status.

RESULTS

A total of 523 individuals were included, with 117 (22%) in the CALD migrant cohort and 406 (78%) in the Australian-born cohort. CALD migrants displayed a statistically significant difference in time from diagnosis to commencement of first treatment for radiation (P = 0.03) and surgery (P = 0.02) and had 16.6 times higher odds of declining recommended chemotherapy than those born in Australia (P = 0.00). Survivorship indicators favoured CALD migrants in mean time from diagnosis to death, however their odds of experiencing disease progression during the study period were 1.6 times higher than those born in Australia (P = 0.04). Service utilisation measures displayed that CALD migrants exhibited higher numbers of unplanned admissions (P = < 0.00), longer cumulative length of those admissions (P = < 0.00) and higher failure to attend scheduled appointments (P = < 0.00).

CONCLUSION

This novel study has produced valuable findings in the areas of treatment, survivorship, and service utilisation for a neglected population in cancer research. The differences identified suggest potential issues of institutional inaccessibility. Future research is needed to examine the clinical impacts of these health differences in the field of cancer care, including the social and institutional determinants of influence.

Diminishing racial disparities in the treatment of colon adenocarcinoma

Background

Prior research has demonstrated racial disparities in the treatment of colon cancer. We sought to determine if treatment disparities persist.

Methods

Patients with colon adenocarcinoma diagnosed from 2012 to 2016 were identified using the Surveillance, Epidemiology and End Results database. Associations between race and clinical characteristics were assessed using Chi square tests. The likelihood of receiving treatment based on race was assessed using logistic regression.

Results

Of 18,841 patients, 69.7% were White, 10.2% Black, 8.7% Hispanic and 11.4% Asian. Among patients with early-stage disease (stage I or II), 96.1% of Whites, 94.6% of Blacks, 95.6% of Hispanics and 97.7% of Asians underwent surgery (p = 0.01), while 8.9% of Whites, 9.3% of Blacks, 12.4% of Hispanics and 8.9% of Asians received chemotherapy (p = 0.03). For years 2012 to 2016 collectively, Blacks with early-stage disease were less likely than Whites to undergo any surgery (aOR = 0.54; 95% CI: 0.36 - 0.81) and more likely to receive neither surgery nor chemotherapy (aOR = 1.91; 95% CI: 1.25 - 2.93). However, when assessing each year individually, the most recent years revealed no difference in the likelihood of receiving surgery in (aOR = 0.45; 95% CI: 0.16 - 1.29 in 2016) or receiving neither surgery nor chemotherapy (aOR = 2.17; 95% CI: 0.70 - 6.70 in 2016).

Conclusion

Racial disparities in the treatment of colon adenocarcinoma have improved in recent years. Health care providers must continue to provide equitable, evidence-based care to ensure that treatment disparities are eliminated.

Racial disparities in treatments and mortality among a large population-based cohort of older men and women with colorectal cancer

BACKGROUND

There were racial disparities in treatment and mortality among patients with colorectal cancer, but few studies incorporated information on hypertension and diabetes and their treatment status.

PATIENTS AND METHODS

The study identified 101,250 patients from Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database in the United States who were diagnosed with colorectal cancer at age ≥65 years between 2007 and 2015 with follow-up to December 2016.

RESULTS

There were substantial racial and ethnic disparities in the prevalence of hypertension and diabetes in patients with colorectal cancer, in receiving chemotherapy and radiation therapy, and in receiving antihypertensive and antidiabetic treatment. Racial disparities in receiving these therapies remained significant in this large cohort of Medicare beneficiaries after stratifications by private health insurance status at the time of cancer diagnosis and by tumor stage. Non-Hispanic black patients had a significantly higher risk of all-cause mortality (hazard ratio: 1.07, 95% CI: 1.04-1.10), which remained significantly higher (1.05, 1.02-1.08) after adjusting for patient sociodemographics, tumor factors, comorbidity and treatments as compared to non-Hispanic white patients. The adjusted risk of colorectal cancer-specific mortality was also significantly higher (1.08, 1.04-1.12) between black and white patients.

CONCLUSIONS

There were substantial racial disparities in prevalence of hypertension and diabetes in men and women diagnosed with colorectal cancer and in receipt of chemotherapy, radiation therapy, antihypertensive and antidiabetic treatment. Black patients with colorectal cancer had a significantly higher risk of all-cause mortality and colorectal cancer-specific mortality than whites, even after adjusting for sociodemographic characteristics, tumor factors, comorbidity scores, and treatments.

Racial Disparities in Colorectal Cancer Care for Black Patients: Barriers and Solutions

Racial disparities in colorectal cancer for Black patients have led to a significant mortality difference when compared to White patients, a gap which has remained to this day. These differences have been linked to poorer quality insurance and socioeconomic status in addition to lower access to high-quality health care resources, which are emblematic of systemic racial inequities. Disparities impact nearly every point along the colorectal cancer care continuum and include barriers to screening, surgical care, oncologic care, and surveillance. These critical faults are the driving forces behind the mortality difference Black patients face. Health care systems should strive to correct these disparities through both cultural competency at the provider level and public policy change at the national level.

Race, Age, Gender, and Insurance Status: A Comparative Analysis of Access to and Quality of Gastrointestinal Cancer Care

BACKGROUND

Socioeconomics, demographics, and insurance status play roles in healthcare access. Considering the limited resources available, understanding the relative impact of disparities helps prioritize programs designed to overcome them. This study evaluates gastrointestinal cancer care disparity by comparing the impact of different patient factors across oncologic care metrices.

METHODS

A multi-institutional prospectively maintained cancer database was reviewed retrospectively for gastrointestinal cancers (esophagus, stomach, liver, pancreas, colorectal, and hepato-pancreato-biliary) from 2007 to 2017 to assess quality of care provided. Quality of care was defined by clinical course following national guidelines for the respective cancer. This included surgical intervention, chemotherapy, palliative care, and minimal delay to treatment/diagnosis. Logistic regression was used to adjust for confounders and identify factors associated with quality of care. Kaplan-Meier survival curves were compared using log-rank test.

RESULTS

One thousand seventy-two patients were identified. Survival improved in patients with private insurance compared to government-funded options [median overall survival (mOS) 57.8 vs. 21.2 months; P < .001]. Private insurance also correlated with earlier stage at diagnosis [stages I-II = 50.9% vs. 37.5%, stages III-IV = 37.7% vs. 49.1%, P < .001], increased chemotherapy use [44.2% vs. 37.1%, P < .001], and more surgical intervention [62.4% vs. 48.8%, P < .001]. Outcomes were inferior for Black Americans, including trend towards lower rate of surgical treatment [42% vs. 54%, P = .058] and worse survival in private insurance carriers [mOS 7.8 vs. 57.8 months, P = .021] and those with early stage disease [mOS 39.2 vs. 81.5 months, P = .045] compared to White counterparts.

CONCLUSIONS

Insurance status has the strongest impact on the quality of gastrointestinal oncologic care with negative synergistic negative effect of race for Black Americans. While governmental programs aim to improve equality of care, there remains significant disparity compared to private insurance. Moreover, private insurance doesn't correct disparity for Black Americans, suggesting the need to address racial imbalances in cancer care.

Racial Disparities in Treatment for Rectal Cancer at Minority-Serving Hospitals

BACKGROUND

Racial disparities exist in patients with rectal cancer with respect to both treatment and survival. Minority-serving hospitals (MSHs) provide healthcare to a disproportionately large percent of minority patients in the USA. We examined the effects of rectal cancer treatment at MSH to understand drivers of these disparities.

METHODS

The NCDB was queried (2004-2015), and patients diagnosed with stage II or III rectal adenocarcinoma were identified. Racial case mix distribution was calculated at the institutional level, and MSHs were defined as those within the top decile of Black and Hispanic patients. Logistic regression was used to identify predictors of receipt of standard of care treatment. Survival was assessed using the Kaplan-Meier method, and Cox proportional hazards models were used to evaluate adjusted risk of death. Analyses were clustered by facility.

RESULTS

A total of 68,842 patients met the inclusion criteria. Of these patients, 63,242 (91.9%) were treated at non-MSH, and 5600 (8.1%) were treated at MSH. In multivariable analysis, treatment at MSH (OR 0.70 95%CI 0.61-0.80 p < 0.001) and Black race (OR 0.75 95%CI 0.70-0.81 p < 0.001) were associated with significantly lower odds of receiving standard of care. In adjusted analysis, Black patients had a significantly higher risk of mortality (HR 1.20 95%CI 1.14-1.26 p < 0.001).

CONCLUSIONS

Treatment at MSH institutions and Black race were associated with significantly decreased odds of receipt of recommended standard therapy for locally advanced rectal adenocarcinoma. Survival was worse for Black patients compared to White patients despite adjustment for receipt of standard of care.

Association of Cumulative Social Risk and Social Support With Receipt of Chemotherapy Among Patients With Advanced Colorectal Cancer

IMPORTANCE

Approximately 38% of patients with advanced colorectal cancer do not receive chemotherapy.

OBJECTIVE

To determine whether cumulative social risk (ie, multiple co-occurring sociodemographic risk factors) is associated with lower receipt of chemotherapy among patients with advanced colorectal cancer and whether social support would moderate this association.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional, population-based, mailed survey study was conducted from 2012 to 2014. Participants were recruited between 2011 and 2014 from all adults within 1 year after diagnosis of stage III colorectal cancer in the Detroit, Michigan, and State of Georgia Surveillance, Epidemiology, End-Results cancer registries. Patients were eligible if they were aged 18 years or older, had undergone surgery 4 or more months ago, did not have stage IV cancer, and resided in the registry catchment areas. Data analyses were conducted from March 2017 to April 2021.

MAIN OUTCOMES AND MEASURES

The primary outcome was receipt of chemotherapy. Cumulative social risk represented a sum of 8 risk factors with the potential to drain resources from participants' cancer treatment (marital status, employment, annual income, health insurance, comorbidities, health literacy, adult caregiving, and perceived discrimination). Social support was operationalized as emotional support related to colorectal cancer diagnosis.

RESULTS

Surveys were mailed to 1909 eligible patients; 1301 completed the survey (response rate, 68%). A total of 1087 participants with complete data for key variables were included in the sample (503 women [46%]; mean [SD] age, 64 [13] years). Participants with 3 or more risk factors were less likely to receive chemotherapy than participants with 0 risk factors (3 factors, odds ratio [OR], 0.48 [95% CI, 0.26-0.87]; 4 factors, OR, 0.41 [95% CI, 0.21-0.78]; 5 factors, OR, 0.42 [95% CI, 0.20-0.87]; ≥6 factors, OR, 0.22 [95% CI, 0.09-0.55]). Participants with 2 or more support sources had higher odds of undergoing chemotherapy than those without social support (2 sources, OR, 3.05 [95% CI, 1.36-6.85]; 3 sources, OR, 3.24 [95% CI, 1.48-7.08]; 4 sources, OR, 3.69 [95% CI, 1.71-7.97]; 5 sources, OR, 4.40 [95% CI, 1.98-9.75]; ≥6 sources, OR 5.95 [95% CI, 2.58-13.74]). Within each social support level, participants were less likely to receive chemotherapy as cumulative social risk increased.

CONCLUSIONS AND RELEVANCE

Cumulative social risk was associated with reduced receipt of chemotherapy. These associations were mitigated by social support. Assessing cumulative social risk may identify patients with colorectal cancer who are at higher risk for omitting chemotherapy who can be targeted for support programs to address social disadvantage and increase social support.

Analysis of racial disparities in the treatment and outcomes of colorectal cancer in young adults

BACKGROUND

The incidence of colorectal cancer (CRC) in young adults is increasing. Minority populations with CRC are known to have worse survival outcomes. The aim of this study is to evaluate adults under age 50 years with CRC by race and ethnicity.

METHODS

Data were obtained from all US hospitals that contributed to the National Cancer Database (NCDB) between 2004 and 2013. Univariate and multivariable testing was done to identify factors associated with patient outcome. Kaplan-Meier analysis and Cox proportional hazards models were used for association between patient characteristics and survival.

RESULTS

A total of 83,449 patients between 18 and 50 years of age were identified. Median age was 45 years (SD ± 6), with male preponderance (53.9%). 72% were non-Hispanic Whites (NHW), Blacks (AA) were 15.1% and Hispanics (who did not identify as Blacks) were 8.3% of the study population. Distribution across stages IIV was 15.6%, 22.4%, 33.9% and 27% consecutively. 41.8% of NHW and 28.4% of AA had rectal cancers (p < 0.001). Despite equally receiving standard of care (SOC) as per national guidelines, AA had significantly lower 5-year survival rates (58.8%) compared to Hispanics (64.8%) and NHW (66.9%; HR 1.42; 1.38-1.46; p < 0.001). Furthermore, NHW (HR 0.85; 0.81-0.88; p < 0.001) and Hispanics (HR 0.75; 0.70-0.79; p < 0.001) were more likely to benefit from chemotherapy compared to AA. SOC utilization was associated with improved survival across all racial groups, especially in AA (HR 0.64; 0.60-0.69; p < 0.001).

CONCLUSION

Despite comparable rates of SOC utilization, AA young adults had worse survival outcomes compared to other races. More colon (compared to rectal) cancers in AA may have contributed to their worse outcomes.

Racial Disparities in the Presentation and Treatment of Colorectal Cancer: A Statewide Cross-sectional Study

BACKGROUND

Non-Hispanic blacks (NHB) and Hispanics often present with advanced colorectal cancer (CRC). The aim of the study was to characterize CRC differences among Hispanics, NHB, and non-Hispanic whites (NHW).

METHODS

A cross-sectional analysis and logistic regression of 2009 Florida Agency for Healthcare Administration Hospital Admission Database data for CRC using the International Classification of Diseases, 9th Revision, Clinical Modification codes was performed. Outcomes included CRC location, frequency of metastasis and colectomy rates. Each minority group was compared with NHW.

RESULTS

A total of 34,577 patients were NHW, 5190 were NHB, and 5033 were Hispanic. NHB had more proximal CRC [odds ratio (OR), 1.17; 95% confidence interval (CI), 1.09-1.25; P<0.0001]; Hispanics had more distal CRC (OR, 0.90; 95% CI, 0.83-0.96; P=0.0024). Hispanics had increased metastases (OR, 1.11; 95% CI, 1.02-1.22; P=0.04). NHB and Hispanics underwent fewer colectomies [(OR, 0.93; 95% CI, 0.86-0.99; P=0.03) and (OR, 0.9; 95% CI, 0.84-0.97; P=0.001), respectively].

CONCLUSIONS

Disparities in CRC metastases and colectomy rates exist among these racial groups in Florida. This work should serve as a foundation to study potential causes and to design culture-specific interventions.

Racial differences in colorectal cancer survival at a safety net hospital

BACKGROUND

While racial disparity in colorectal cancer survival have previously been studied, whether this disparity exists in patients with metastatic colorectal cancer receiving care at safety net hospitals (and therefore of similar socioeconomic status) is poorly understood.

METHODS

We examined racial differences in survival in a cohort of patients with stage IV colorectal cancer treated at the largest safety net hospital in the New England region, which serves a population with a majority (65%) of non-Caucasian patients. Data was extracted from the hospital's electronic medical record. Survival differences among different racial and ethnic groups were examined graphically using Kaplan-Meier analysis. A univariate cox proportional hazards model and a multivariable adjusted model were generated.

RESULTS

Black patients had significantly lower overall survival compared to White patients, with median overall survival of 1.9 years and 2.5 years respectively. In a multivariate analysis, Black race posed a significant hazard (HR 1.70, CI 1.01-2.90, p=0.0467) for death. Though response to therapy emerged as a strong predictor of survival (HR=0.4, CI=0.2-0.7, p=0.0021), it was comparable between Blacks and Whites.

CONCLUSIONS

Despite presumed equal access to healthcare and socioeconomic status within a safety-net hospital system, our results reinforce findings from previous studies showing lower colorectal cancer survival in Black patients, and also point to the importance of investigating other factors such as genetic and pathologic differences.

Ethnic differences in colon cancer care in the Netherlands: a nationwide registry-based study

Background

Ethnic differences in colon cancer (CC) care were shown in the United States, but results are not directly applicable to European countries due to fundamental healthcare system differences. This is the first study addressing ethnic differences in treatment and survival for CC in the Netherlands.

Methods

Data of 101,882 patients diagnosed with CC in 1996–2011 were selected from the Netherlands Cancer Registry and linked to databases from Statistics Netherlands. Ethnic differences in lymph node (LN) evaluation, anastomotic leakage and adjuvant chemotherapy were analysed using stepwise logistic regression models. Stepwise Cox regression was used to examine the influence of ethnic differences in adjuvant chemotherapy on 5-year all-cause and colorectal cancer-specific survival.

Results

Adequate LN evaluation was significantly more likely for patients from ‘other Western’ countries than for the Dutch (OR 1.09; 95% CI 1.01–1.16). ‘Other Western’ patients had a significantly higher risk of anastomotic leakage after resection (OR 1.24; 95% CI 1.05–1.47). Patients of Moroccan origin were significantly less likely to receive adjuvant chemotherapy (OR 0.27; 95% CI 0.13–0.59). Ethnic differences were not fully explained by differences in socioeconomic and hospital-related characteristics. The higher 5-year all-cause mortality of Moroccan patients (HR 1.64; 95% CI 1.03–2.61) was statistically explained by differences in adjuvant chemotherapy receipt.

Conclusion

These results suggest the presence of ethnic inequalities in CC care in the Netherlands. We recommend further analysis of the role of comorbidity, communication in patient-provider interaction and patients’ health literacy when looking at ethnic differences in treatment for CC.

Communication challenges experienced by migrants with cancer: A comparison of migrant and English-speaking Australian-born cancer patients

Objectives

Understanding the difficulties faced by different migrant groups is vital to address disparities and inform targeted health‐care service delivery. Migrant oncology patients experience increased morbidity, mortality and psychological distress, with this tentatively linked to language and communication difficulties. The objective of this exploratory study was to investigate the communication barriers and challenges experienced by Arabic, Greek and Chinese (Mandarin and Cantonese) speaking oncology patients in Australia.

Methods

This study employed a cross‐sectional design using patient‐reported outcome survey data from migrant and English‐speaking Australian‐born patients with cancer. Patients were recruited through oncology clinics and Australian state cancer registries. Data were collected regarding patient clinical and demographic characteristics and health‐care and communication experiences. Data from the clinics and registries were combined for analysis.

Results

Significant differences were found between migrant groups in demographic characteristics, communication and health‐care experiences, and information and care preferences. Chinese patients cited problems with understanding medical information, the Australian health‐care system, and communicating with their health‐care team. Conversely, Arabic‐ and Greek‐speaking patients reported higher understanding of the health‐care system, and less communication difficulties.

Conclusions

Our study findings suggest that migrant groups differ from each other in their health communication expectations and requirements. Lower education and health literacy of some groups may play a role in poorer health outcomes. Public health interventions and assistance provided to migrants should be tailored to the specific needs and characteristics of that language or cultural group. Future research directions are discussed.

Racial Disparities in Colorectal Carcinoma Incidence, Severity and Survival Times Over 10 Years: A Retrospective Single Center Study

BACKGROUND

Colorectal cancer (CRC) is the third leading cause of cancer-related deaths in the United States. Although studies have been performed on malignancy behavior in African Americans and Caucasians, scant data are present on other minority racial groups.

METHODS

A retrospective single center study was performed where 1,860 patient charts with a diagnosis of CRC from January 1, 2004 to December 31, 2014 were reviewed. Data collected on each patient included age, gender, ethnicity, primary site and histological stage at the time of diagnosis. Survival time over the course of 5 years was documented for patients from January 1, 2004 to December 31, 2009. Comparisons were made amongst different racial groups for the above mentioned factors.

RESULTS

Study population consisted of 27.09% African Americans, 65.61% Caucasians, 3.86% Hispanics, 0.54% South Asians, 1.03% Arabs, 0.54% Asians and 0.22% American Indians. Mean age of CRC presentation was found to be significantly different (P < 0.05) between the three largest racial groups: 71 years for Caucasians, 69 years for African Americans, and 61 years for Hispanics. African Americans (27.09%) and Hispanics (28.79%) presented predominantly at stage IV in comparison to other racial groups. Caucasians presented predominantly at stage III (24.84%). The rectum was the most common site of CRC across all racial groups with the exception of Asians, where sigmoid colon was the predominant site (30%). Adenocarcinoma remained the predominant cancer type in all groups. Hispanics had relatively higher incidence rate of carcinoid tumor (12.68%). Survival time analysis showed that Caucasians tend to have better survival probability over 5 years after initial diagnosis as compared to African Americans and Hispanic (P < 0.05).

CONCLUSION

There is lack of studies performed on minority racial groups in North America. Our study highlighted some important clinical differences of CRC presentation in different racial groups which are not well studied and can be used to formulate future multi-center studies to assess disease behavior.

Colorectal Cancer in African Americans: An Update

This review is an update to the American College of Gastroenterology (ACG) Committee on Minority Affairs and Cultural Diversity's paper on colorectal cancer (CRC) in African Americans published in 2005. Over the past 10 years, the incidence and mortality rates of CRC in the United States has steadily declined. However, reductions have been strikingly much slower among African Americans who continue to have the highest rate of mortality and lowest survival when compared with all other racial groups. The reasons for the health disparities are multifactorial and encompass physician and patient barriers. Patient factors that contribute to disparities include poor knowledge of benefits of CRC screening, limited access to health care, insurance status along with fear and anxiety. Physician factors include lack of knowledge of screening guidelines along with disparate recommendations for screening. Earlier screening has been recommended as an effective strategy to decrease observed disparities; currently the ACG and American Society of Gastrointestinal Endoscopists recommend CRC screening in African Americans to begin at age 45. Despite the decline in CRC deaths in all racial and ethnic groups, there still exists a significant burden of CRC in African Americans, thus other strategies including educational outreach for health care providers and patients and the utilization of patient navigation systems emphasizing the importance of screening are necessary. These strategies have been piloted in both local communities and Statewide resulting in notable significant decreases in observed disparities.

A comparison of 12-gene colon cancer assay gene expression in African American and Caucasian patients with stage II colon cancer

Background

African American (AA) colon cancer patients have a worse prognosis than Caucasian (CA) colon cancer patients, however, reasons for this disparity are not well understood. To determine if tumor biology might contribute to differential prognosis, we measured recurrence risk and gene expression using the Oncotype DX® Colon Cancer Assay (12-gene assay) and compared the Recurrence Score results and gene expression profiles between AA patients and CA patients with stage II colon cancer.

Methods

We retrieved demographic, clinical, and archived tumor tissues from stage II colon cancer patients at four institutions. The 12-gene assay and mismatch repair (MMR) status were performed by Genomic Health (Redwood City, California). Student’s t-test and the Wilcoxon rank sum test were used to compare Recurrence Score data and gene expression data from AA and CA patients (SAS Enterprise Guide 5.1).

Results

Samples from 122 AA and 122 CA patients were analyzed. There were 118 women (63 AA, 55 CA) and 126 men (59 AA, 67 CA). Median age was 66 years for AA patients and 68 for CA patients. Age, gender, year of surgery, pathologic T-stage, tumor location, the number of lymph nodes examined, lymphovascular invasion, and MMR status were not significantly different between groups (p = 0.93). The mean Recurrence Score result for AA patients (27.9 ± 12.8) and CA patients (28.1 ± 11.8) was not significantly different and the proportions of patients with high Recurrence Score values (≥41) were similar between the groups (17/122 AA; 15/122 CA). None of the gene expression variables, either single genes or gene groups (cell cycle group, stromal group, BGN1, FAP, INHBA1, Ki67, MYBL2, cMYC and GADD45B), was significantly different between the racial groups. After controlling for clinical and pathologic covariates, the means and distributions of Recurrence Score results and gene expression profiles showed no statistically significant difference between patient groups.

Conclusion

The distribution of Recurrence Score results and gene expression data was similar in a cohort of AA and CA patients with stage II colon cancer and similar clinical characteristics, suggesting that tumor biology, as represented by the 12-gene assay, did not differ between patient groups.

Health disparities in colorectal cancer among racial and ethnic minorities in the United States

In the 2010 Census, just over one-third of the United States (US) population identified themselves as being something other than being non-Hispanic white alone. This group has increased in size from 86.9 million in 2000 to 111.9 million in 2010, representing an increase of 29 percent over the ten year period. Per the American Cancer Society, racial and ethnic minorities are more likely to develop cancer and die from it when compared to the general population of the United States. This is particularly true for colorectal cancer (CRC). The primary aim of this review is to highlight the disparities in CRC among racial and ethnic minorities in the United States. Despite overall rates of CRC decreasing nationally and within certain racial and ethnic minorities in the US, there continue to be disparities in incidence and mortality when compared to non-Hispanic whites. The disparities in CRC incidence and mortality are related to certain areas of deficiency such as knowledge of family history, access to care obstacles, impact of migration on CRC and paucity of clinical data. These areas of deficiency limit understanding of CRC's impact in these groups and when developing interventions to close the disparity gap. Even with the implementation of the Patient Protection and Affordable Healthcare Act, disparities in CRC screening will continue to exist until specific interventions are implemented in the context of each of racial and ethnic group. Racial and ethnic minorities cannot be viewed as one monolithic group, rather as different segments since there are variations in incidence and mortality based on natural history of CRC development impacted by gender, ethnicity group, nationality, access, as well as migration and socioeconomic status. Progress has been made overall, but there is much work to be done.

Genetic Basis for Colorectal Cancer Disparities

African Americans suffer the highest burden from colorectal cancer (CRC) in the USA. Studies have suggested that healthcare access and poorer utilization of preventive services may be playing more of a role in this disparity. However, African Americans also tend to develop CRC at younger ages and are more likely to have proximal cancers. This raises the possibility of higher genetic predisposition to CRC among African Americans and this has not been well studied. In this article, we reviewed possible genetic basis underpinning biological differences in CRC burden in the USA.

The Relationship between Neighborhood Immigrant Composition, Limited English Proficiency, and Late-Stage Colorectal Cancer Diagnosis in California

Despite the availability of effective early detection technologies, more than half (61%) of colorectal cancers in the United States and 55% in California are identified at an advanced stage. Data on colorectal cancer patients (N = 35,030) diagnosed from 2005 to 2007 were obtained from the California Cancer Registry. Multivariate analyses found a relationship among neighborhood concentration of recent immigrants, neighborhood rates of limited English proficiency, and late-stage colorectal cancer diagnosis. Hispanics living in neighborhoods with a greater percentage of recent immigrants (compared to the lowest percentage) had greater odds (OR 1.57, 95% CI 1.22, 2.02) of late-stage diagnosis whereas Hispanics living in neighborhoods with the highest percentage of limited English proficiency (compared to the lowest percentage) had lower odds (OR .71, 95% CI .51, .99) of late-stage diagnosis. These relationships were not observed for other ethnic groups. Results highlight the complex relationship among race/ethnicity, neighborhood characteristics, and colorectal cancer stage at diagnosis.

Outcomes in non-metastatic colorectal cancer

The measurement of outcomes in non-metastatic colon and rectal cancer patients is a multi-dimensional endeavor involving prediction tools, standard of care, and best treatment guidelines. Socioeconomic, demographic, and racial impacts on outcome must be carefully considered. Consideration must also be given to measures of cost, quality, and healthcare delivery in response to initiatives meant to optimize patient health while maintaining quality of life.

Racial disparity in colorectal cancer: the role of equal treatment

BACKGROUND

Racial disparity exists in colorectal cancer outcomes. The reasons for this are multifactorial.

OBJECTIVE

The aim of this study was to evaluate the role of equal treatment of blacks and whites in the elimination of racial disparity in colorectal cancer outcomes.

DESIGN

A retrospective cohort study of 878 patients with colorectal cancer diagnosed between 1998 and 2008 was done at a University tertiary referral center. Demographic variables including age, sex, and race were abstracted. Tumor-specific variables including American Joint Committee on Cancer stage, anatomic tumor location, vital status, and survival were obtained. Treatment-specific variables including surgery, chemotherapy, radiotherapy, and follow-up were also obtained. Racial differences in these variables were studied and their effect on overall survival was determined by using univariate and multivariate analyses. The findings were then compared with previous data from our institution.

SETTING

University tertiary referral center.

MAIN OUTCOME MEASURES

The primary outcomes measured were overall survival and cancer-specific mortality.

RESULTS

A total of 878 patients met the inclusion criteria, 186 (21.2%) of whom were black. Blacks were significantly younger at diagnosis in comparison with whites, with a median (quartiles) age of 55 years (28-87) compared with 59 years (23-94) (p = 0.0012). Equal proportions of blacks (78.5%) and whites (79.2%) underwent surgery (p = 0.84), similar proportions of blacks (55.4%) and whites (60.8%) received chemotherapy (p = 0.18), and similar proportions of blacks (17.2%) and whites (20.5%) received radiation therapy (p = 0.31). There was no difference in overall survival or cancer-specific mortality between the 2 racial groups. Univariate analysis showed American Joint Committee on Cancer stage and surgery as the only statistically significant factors for overall survival. On multivariate analysis, stage, surgery, and chemotherapy were the only statistically significant factors. Race was not an independent determinant of survival.

CONCLUSIONS

There were no differences in overall survival and cancer-related mortality between blacks and whites, and this may have resulted from identical treatment. The previously noted disparities in treatment and overall survival at our institution have disappeared.

Postoperative chemotherapy use after neoadjuvant chemoradiotherapy for rectal cancer: Analysis of Surveillance, Epidemiology, and End Results-Medicare data, 1998-2007

BACKGROUND

Neoadjuvant chemoradiotherapy followed by tumor resection and postoperative chemotherapy is the standard of care for patients with clinical stage II or III adenocarcinoma of the rectum. Significant variation exists in the receipt of postoperative chemotherapy after resection in this population. The objective of this study was to determine the demographic and clinicopathologic factors associated with the initiation of postoperative chemotherapy in elderly patients with rectal cancer and to identify potential targets for reducing treatment variation.

METHODS

A retrospective cohort study was performed of patients with rectal cancer ages 66 to 80 years who received neoadjuvant chemoradiotherapy and underwent radical resection in the Surveillance, Epidemiology, and End Results-linked Medicare database (1998-2007). Multivariate logistic regression was used to assess chemotherapy use in relation to patient, tumor, and treatment response characteristics.

RESULTS

Among 1492 patients who met the study criteria, 61.5% received adjuvant therapy with 5-fluorouracil. Pathologic stage was the strongest determinant of whether patients received postoperative chemotherapy (48.3% of patients with stage I disease, 59.6% of patients with stage II disease, and 77.6% of patients with stage III disease). Increasing age and postoperative readmission also were associated significantly with a decreased rate of adjuvant therapy initiation.

CONCLUSIONS

Although standard treatment guidelines for locally advanced rectal cancer include postoperative chemotherapy for all patients after neoadjuvant chemoradiotherapy and radical resection, greater than 1 in 3 patients failed to receive adjuvant therapy. Despite the absence of established evidence, treatment decisions appear to be influenced by the findings at surgical pathology.

National disparities in laparoscopic colorectal procedures for colon cancer

INTRODUCTION

Racial disparity in the treatment of colorectal cancer (CRC) has been cited as a potential cause for differences in mortality. This study compares the rates of laparoscopy according to race, insurance status, geographic location, and hospital size.

METHODS

The 2009 Healthcare Cost and Utilization Project: Nationwide Inpatient Sample (HCUP-NIS) database was queried to identify patients with the diagnosis of CRC by the International Classification of Diseases, Ninth Revision (ICD-9) codes. Multivariate logistic regression was performed to look at age, gender, insurance coverage, academic versus nonacademic affiliated institutions, rural versus urban settings, location, and proportional differences in laparoscopic procedures according to race.

RESULTS

A total of 14,502 patients were identified; 4,691 (32.35 %) underwent laparoscopic colorectal procedures and 9,811 (67.65 %) underwent open procedures. The proportion of laparoscopic procedures did not differ significantly by race: Caucasian 32.4 %, African-American 30.04 %, Hispanic 33.99 %, and Asian-Pacific Islander 35.12 (P = 0.08). Among Caucasian and African-American patients, those covered by private insurers were more likely to undergo laparoscopic procedures compared to other insurance types (P ≤ 0.001). The odds of receiving laparoscopic procedure at teaching hospitals was 1.39 times greater than in nonteaching hospitals (95 % confidence interval [CI] 1.29-1.48) and did not differ across race groups. Patients in urban hospitals demonstrated higher odds of laparoscopic surgery (2.24, 95 % CI 1.96-2.56) than in rural hospitals; this relationship was consistent within races. The odds of undergoing laparoscopic surgeries was lowest in the Midwest region (0.89, 95 % CI 0.81-0.97) but higher in the Southern region (1.14, 95 % CI 1.06-1.22) compared with the other regions.

CONCLUSIONS

Nearly one-third of all CRC surgeries are laparoscopic. Race does not appear to play a significant role in the selection of a laparoscopic CRC operation. However, there are significant differences in the selection of laparoscopy for CRC patients based on insurance status, geographic location, and hospital type.

Late presentation of colorectal cancer in a vulnerable population

OBJECTIVES

We examined colorectal cancer (CRC) stage at presentation and mortality in a vulnerable population compared with nationally representative data.

METHODS

CRC cases were identified from San Francisco General Hospital (SFGH) and the Surveillance Epidemiology and End Results (SEER) database.

RESULTS

Fifty-five percent of the SFGH cohort presented with advanced disease, compared with 44% of the SEER cohort. Increased risk of advanced stage at presentation at SFGH compared with SEER was most evident among blacks and Asians. There was weak evidence for worse survival at SFGH compared with SEER overall. This varied by race with poorer survival at SFGH among whites and possibly blacks but some evidence for better survival among Asians. Among CRC patients at SFGH, Asians and Hispanics had better survival than whites and blacks. At SFGH, 44% had a diagnosis of CRC within 1 year of establishing care there. Of those who had established care at SFGH for at least 1 year, only 22% had exposure to CRC screening tests.

CONCLUSIONS

These findings allow examination of CRC presentation by ethnicity in vulnerable populations and identify areas where access and utilization of CRC screening can be improved.

Racial disparity in colorectal cancer: the role of ABO blood group

BACKGROUND

We tested the hypothesis that racial differences that exist in the distribution of ABO blood type would partially explain the racial disparity in overall survival seen in colorectal cancer.

METHODS

retrospective analysis of the cancer registry of a university hospital for patients treated for colorectal cancer between 1996 and 2008. Demographic, tumor-specific, and treatment-specific variables were abstracted. We also obtained ABO blood group data. The primary end point was overall survival. We divided patients into two groups based on where they underwent surgery: the University of Arkansas for Medical Sciences (UAMS) or outside facilities.

RESULTS

Of 833 patients, 182 (21.8%) were black. There was no difference in overall survival between blacks and whites for the entire group (P = 0.61). There was a statistically significant difference in overall survival between patients at the UAMS and outside facilities (P < 0.0001). For the outside facilities group, there was a statistically significant difference in overall survival between blacks and whites (hazard ratio, CI: 1.48 [1.06-2.00]; P = 0.012); no race difference existed for the UAMS group. The ABO blood group had no effect on overall survival. On stage-stratified univariate and multivariate analyses, chemotherapy and surgery were the only statistically significant determinants of survival.

CONCLUSIONS

In this study, racial differences in ABO blood group distribution had no effect on overall survival.

African ancestry is a predictor factor to secondary progression in clinical course of multiple sclerosis

Background. Studies on the clinical course of multiple sclerosis have indicated that certain initial clinical factors are predictive of disease progression. Regions with a low prevalence for disease, which have environmental and genetic factors that differ from areas of high prevalence, lack studies on the progressive course and disabling characteristics of the disease. Objective. To analyse the long-term evolution to the progressive phase of the relapsing-remitting multiple sclerosis and its prognosis factors in mixed population. Methods. We performed a survival study and logistic regression to examine the influence of demographic and initial clinical factors on disease progression. Among 553 relapsing-remitting patients assisted at a Brazilian reference centre for multiple sclerosis, we reviewed the medical records of 150 patients who had a disease for ten or more years. Results. African ancestry was a factor that conferred more risk for secondary progression followed by age at the onset of the disease and the number of relapses in the year after diagnosis. A greater understanding of the influence of ancestry on prognosis serves to stimulate genetics and pharmacogenomics research and may clarify the poorly understood neurodegenerative progression of MS.

Racial disparities in receipt and comparative effectiveness of oxaliplatin for stage III colon cancer in older adults

BACKGROUND

African Americans in the United States have higher rates of colon cancer mortality than other races. This study examines the use of oxaliplatin, a novel chemotherapeutic agent approved in 2004, among African American and Caucasian American patients with stage III colon cancer to determine whether differential receipt or differential effectiveness of the drug may explain the racial disparity in colon cancer mortality.

METHODS

The authors conducted a population-based retrospective cohort study of stage III colon cancer patients aged 65 years and older treated from 2004 through 2006 who initiated chemotherapy within 90 days of surgical resection (N = 1162) using Surveillance, Epidemiology and End Results-Medicare data. Patients receiving oxaliplatin (n = 477) were compared with those receiving 5-fluorouracil without oxaliplatin (n = 685). The authors estimated prevalence ratios and hazard ratios (HRs) using multivariate binomial regression and Cox models to evaluate racial differences in oxaliplatin receipt and survival.

RESULTS

African Americans were as likely as Caucasian Americans to receive oxaliplatin (40.5 vs 41.1%; prevalence ratio, 0.90; 95% confidence interval [CI], 0.71-1.13). Oxaliplatin was associated with lower mortality compared with 5-fluorouracil (HR, 0.76; 95% CI, 0.58-1.00). This benefit appeared stronger among African Americans (HR, 0.31; 95% CI, 0.09-1.05) than Caucasian Americans (HR, 0.80; 95% CI, 0.60-1.06).

CONCLUSIONS

In Medicare-insured patients receiving chemotherapy, the authors observed no meaningful racial disparities in receipt of oxaliplatin and, among those receiving it, potentially better survival among African Americans. Differential receipt and effectiveness of oxaliplatin-containing regimens does not appear to contribute to the previously documented racial disparities in colon cancer survival. Understanding reasons for potentially enhanced effectiveness among African Americans may inform efforts to resolve racial disparities in colon cancer outcomes.

Lower albumin levels in African Americans at colon cancer diagnosis: a potential explanation for outcome disparities between groups?

BACKGROUND AND AIM

Colorectal cancer is the third most common cancer and 3rd leading cause of cancer-related death in the USA. African Americans (AA) have inferior outcomes when matched for diagnosis stage and socioeconomic situation. Nutritional status, at diagnosis and its contribution to the observed cancer outcome disparity, between AA and non-Hispanic whites (nHw) has not been evaluated to date. The aim of the investigation was to determine if differences in nutritional surrogate markers, such as serum albumin and body mass index (BMI), exist at the time of colorectal cancer diagnosis between AA and nHw.

METHODS

The University of Florida College of Medicine-Jacksonville endoscopy database was reviewed for all patients with a biopsied colorectal mass between January 2000 and December 2007. Patients were excluded if histology did not reveal colorectal adenocarcinoma or albumin/BMI was unavailable. Demographic data, tumor location, serum albumin within 60 days of diagnosis, presence of diabetes along with serum HbA1c were obtained.

RESULTS

During the study period, 321 patients had colorectal masses discovered and 156 met entry criteria. There was no difference between ethnic groups regarding gender distribution, tumor location, diabetes presence, or BMI. Mean albumin was significantly less in AA compared to nHw (p < 0.01). This persisted after adjustment for gender, presence/absence of diabetes, and BMI.

CONCLUSIONS

Lower albumin levels in AA indicate poorer nutritional status at colorectal cancer diagnosis compared to nHw. This may contribute to the outcome disparities observed between AA and nHw. Aggressive nutritional interventions to reverse this disparity should be evaluated.

Colorectal cancer: epidemiology, risk factors, and health services

Colorectal carcinoma is the third most common cancer in the United States in both men and women but still remains the second leading cause of cancer-related deaths. The risk of developing colorectal cancer increases with age. Additional risk factors include family history of colorectal cancer, heredity conditions such as polyposis and hereditary nonpolyposis colorectal cancer, and personal history of inflammatory bowel disease, polyps, and cancers. Health services is a new scientific discipline that examines the quality of care, often at the population level, and may examine parts or the entire spectrum of care.

A black-white comparison of the quality of stage-specific colon cancer treatment

BACKGROUND

Several studies have attributed racial disparities in cancer incidence and mortality to variances in socioeconomic status and health insurance coverage. However, an Institute of Medicine report found that blacks received lower quality care than whites after controlling for health insurance, income, and disease severity.

METHODS

To examine the effects of race on colorectal cancer outcomes within a single setting, the authors performed a retrospective cohort study that analyzed the cancer registry, billing, and medical records of 365 university hospital patients (175 blacks and 190 whites) diagnosed with stage II-IV colon cancer between 2000 and 2005. Racial differences in the quality (effectiveness and timeliness) of stage-specific colon cancer treatment (colectomy and chemotherapy) were examined after adjusting for socioeconomic status, health insurance coverage, sex, age, and marital status.

RESULTS

Blacks and whites had similar sociodemographic characteristics, tumor stage and site, quality of care, and health outcomes. Age and diagnostic stage were predictors of quality of care and mortality. Although few patients (5.8%) were uninsured, they were more likely to present at advanced stages (61.9% at stage IV) and die (76.2%) than privately insured and publicly insured patients (p = .002).

CONCLUSIONS

In a population without racial differences in socioeconomic status or insurance coverage, patients receive the same quality of care, regardless of racial distinction, and have similar health outcomes. Age, diagnostic stage, and health insurance coverage remained independently associated with mortality. Future studies of disparities in colon cancer treatment should examine sociocultural barriers to accessing appropriate care in various healthcare settings.

Differences in the progression of primary progressive multiple sclerosis in Brazilians of African descent versus white Brazilian patients

Recent studies have suggested faster clinical progression and greater disability in multiple sclerosis patients of African descent. This study analysed the effect of ethnicity on progression and disability.

Sixty-five patients with primary progressive multiple sclerosis were selected and classified as being of African descent or white. Time from onset of the disease until reaching Expanded Disability Status Scale grades 3, 6, and 8 was assessed, as well as irreversible disability (Expanded Disability Status Scale grade maintained for ≥6 months).

In the African descent group, the median time to reach Expanded Disability Status Scale 3 was 1 year shorter (1 year vs 2 years, p= 0.02), and to reach Expanded Disability Status Scale 6 was 2 years shorter (3 years vs 5 years, p= 0.01) than in the group of white patients. According to the Kaplan—Meier survival curves, patients of African descent reached every disability stage faster than white patients ( p= 0.03, p = 0.04, and p = 0.03, respectively, for Expanded Disability Status Scale grades 3, 6, and 8).

As in United States and European patients of African descent, the more severe and faster progression of multiple sclerosis seen in Brazilian primary progressive multiple sclerosis patients of African descent suggests a possibly greater effect of ethnicity rather than environment on the progression of multiple sclerosis.

Effect of race on colon cancer treatment and outcomes in the Department of Defense healthcare system

PURPOSE

The increase in mortality noted in African Americans with colon cancer is attributed to advanced stage at presentation and disparities in treatment received. The aim of this study was to assess the influence of race on the treatments and survival of colon cancer patients in an equal-access healthcare system.

METHODS

This retrospective cohort study included African American and white patients with colon cancer treated at Department of Defense facilities. Disease stage, surgery performed, chemotherapy used, and overall survival were evaluated.

RESULTS

Of the 6958 colon cancer patients identified, 1115 were African American. African Americans presented more frequently with stage IV disease, 23% vs 17% for whites (P < .001). There was no difference in surgical resection rates for African American or whites (85.8% vs 85.5%, respectively; chi2, P > .05). There was no difference in the use of systemic chemotherapy for stage III colon cancer (73.5% for African Americans vs 72.2% for whites; chi2, P > .05) or stage IV colon cancer (56.3% for African Americans vs 54.4% for whites; chi2, P > .05). The overall 5-year survival rate was similar for African American and white patients (56.1% vs 58.5%, respectively; log-rank, P > .05). After adjusting for gender, age, tumor grade, and stage, African American race was not a risk factor for survival in Cox proportional hazard analysis (hazard ratio, 0.981; 95% confidence interval, 0.888-1.084).

CONCLUSIONS

In an equal-access healthcare system, African American race is not associated with an increase in mortality. African American patients undergo surgery and chemotherapy is administered at rates equal to whites for all stages of colon cancer.

Disparities in cancer care: an operative perspective

BACKGROUND

Health disparities in cancer care have been described and stem from a complex interplay of patient, provider, and instutional factors.

METHODS

A review of the literature describing disparities in aspects of cancer care was performed.

RESULTS

Disparities in outcomes including overall survival for minority populations have been demonstrated to exist for race, age, and socioeconomic status.

CONCLUSION

Disparities in cancer care and outcomes clearly exist for many poorly understood reasons. After a diagnosis of cancer, barriers to care may develop at multiple points along the course of the patient's disease.

(13)C-5-FU breath test current status and future directions: a comprehensive review

Breath tests (BTs) represent a safe non-invasive alternative strategy that could provide valuable diagnostic information in conditions like fat malabsorption, carbohydrate (lactose and fructose) malabsorption, liver dysfunction, impaired gastric emptying, abnormal small bowel transit time, small intestinal bacterial overgrowth and Helicobacter pylori infection. To date, despite the availability of a number of breath tests, only three have gained approval by the FDA for application in a clinical setting ((13)C-urea breath test for the detection of H. pylori; NO breath test for monitoring asthma and alkane breath test for heart transplant rejection). Unfortunately, none of these tests investigate cancer patients or response to cancer chemotherapy. Several years ago it was realized that the presence of a reliable non-invasive approach could assist in the detection of patients at risk of developing severe life-threatening toxicities prior to the administration of fluoropyrimidines (e.g. 5-FU) or related cancer chemotherapy. 5-FU toxicity results mainly from deficient uracil catabolism. This review discusses the development of a BT that utilizes an orally administered pyrimidine ([2-(13)C]-uracil) which is metabolized via the same catabolic pathway as 5-FU. This ([2-(13)C]-uracil) breath test could provide a valuable addition to the patients' standard of care.

Racial differences in colorectal cancer survival in the Detroit Metropolitan Area

BACKGROUND

Colorectal carcinoma is the second most common cause of cancer death with African Americans having lower survival compared with White Americans. The purpose of this study was to investigate the effect of demographics, clinical factors, and socioeconomic status (SES) on racial disparities in colorectal cancer survival in the Detroit Metropolitan Area.

METHODS

The study population included 9078 individuals with primary invasive colorectal cancer identified between 1988 and 1992 through the Surveillance, Epidemiology, and End Results (SEER) program. Demographics, clinical information, and survival were obtained through SEER. SES was categorized using occupation, educational level, and poverty status at the census tract level. Kaplan-Meier survival curves and Cox proportional hazards regression were used to compare overall survival by race.

RESULTS

African Americans were more likely to be diagnosed with stage IV disease (P < .001), and to reside within poor census tracts (P < .001) compared with White Americans. Unadjusted analysis showed that African Americans had a significantly higher risk of death compared with their White American counterparts (hazards ratio [HR], 1.13; 95% confidence interval [CI], 1.07-1.20). After adjusting for age, marital status, sex, SES group, TNM stage, and treatment, race was no longer significantly associated with overall survival (HR, 1.00; 95% CI, 0.92-1.09). Similar results were seen with colorectal cancer-specific survival.

CONCLUSIONS

Racial disparities in colorectal cancer survival dissipate after adjusting for other demographic and clinical factors. These results can potentially affect medical guidelines regarding screening and treatment, and possibly influence public health policies that can have a positive impact on equalizing racial differences in access to care.

Disparities in colorectal cancer in African-Americans vs Whites: Before and after diagnosis

There are differences between African-American and white patients with colorectal cancer, concerning their characteristics before and after diagnosis. Whites are more likely to adhere to screening guidelines. This is also the case among people with positive family history. Colorectal cancer is more frequent in Blacks. Studies have shown that that since 1985, colon cancer rates have dipped 20% to 25% for Whites, while rates have gone up for African-American men and stayed the same for African-American women. Overall, African-Americans are 38% to 43% more likely to die from colon cancer than are Whites. Furthermore, it seems that there is an African-American predominance in right-sited tumors. African Americans tend to be diagnosed at a later stage, to suffer from better differentiated tumors, and to have worse prognosis when compared with Whites. Moreover, less black patients receive adjuvant chemotherapy for resectable colorectal cancer or radiation therapy for rectal cancer. Caucasians seem to respond better to standard chemotherapy regimens than African-Americans. Concerning toxicity, it appears that patients of African-American descent are more likely to develop 5-FU toxicity than Whites, possibly because of their different dihydropyridine dehydrogenase status. Last but not least, screening surveillance seems to be higher among white than among black long-term colorectal cancer survivors. Socioeconomic and educational status account for most of these differences whereas little evidence exists for a genetic contribution in racial disparity. Understanding the nature of racial differences in colorectal cancer allows tailoring of screening and treatment interventions.

Examining racial disparities in colorectal cancer care

African Americans are disproportionately burdened with colorectal cancer. Although incidence and mortality rates have declined in the past two decades, the disparity in health outcomes has progressively increased. This comprehensive review examines the existing literature regarding racial disparities in colorectal cancer screening, stage at diagnosis, and treatment to determine if differences exist in the quality of care delivered to African Americans. A comprehensive review of relevant literature was performed. Two databases (EBSCOHOST Academic Search Premier and Scopus) were searched from 2000 to 2007. Articles that assessed racial disparities in colorectal cancer screening, stage of disease at diagnosis, and treatment were selected. The majority of studies identified examined colorectal cancer screening outcomes. Although racial disparities in screening have diminished in recent years, African American men and women continue to have higher colorectal cancer incidence and mortality rates and are diagnosed at more advanced stages. Several studies regarding stage of disease at diagnosis identified socioeconomic status (SES) and health insurance status as major determinants of disparity. However, some studies found significant racial disparities even after controlling for these factors. Racial disparities in treatment were also found at various diagnostic stages. Many factors affecting disparities between African Americans and Whites in colorectal cancer incidence and mortality remain unexplained. Although the importance of tumor biology, genetics, and lifestyle risk factors have been established, prime sociodemographic factors need further examination to understand variances in the care of African Americans diagnosed with colorectal cancer.

A matter of race: early-versus late-stage cancer diagnosis

We compared the stage at which cancer is diagnosed and survival rates between African Americans and whites, for thirty-four solid tumors, using the population-based Surveillance Epidemiology and End Results (SEER) database. Whites were diagnosed at earlier stages than African Americans for thirty-one of the thirty-four tumor sites. Whites were significantly more likely than blacks to survive five years for twenty-six tumor sites; no cancer site had significantly superior survival among African Americans. These differences cannot be explained by screening behavior or risk factors; they point instead to the need for broad-based strategies to remedy racial inequality in cancer survival.

Race affects access to nephrectomy but not survival in renal cell carcinoma

OBJECTIVES

To assess whether, in contemporary patients with renal cell carcinoma (RCC), access to nephrectomy is the same between the Blacks and Whites, and that there is no difference in mortality after stratification for treatment type.

PATIENTS AND METHODS

The effect of race has received little attention in RCC; only two reports have addressed and suggested the presence of racial disparities, including access to nephrectomy and survival after nephrectomy, where Black patients were disadvantaged relative to Whites. We used the Surveillance, Epidemiology and End Results data from 12 516 patients of all stages diagnosed and treated for RCC between 2000 and 2004. The effect of race (Black vs White) on nephrectomy rate was addressed in logistic regression and binomial regression models, and Cox regression models tested the effect of race on overall survival.

RESULTS

Black patients were 50% less likely to have a nephrectomy than their White counterparts. However, race had no effect on overall survival when the entire cohort was assessed, as well as in subgroups of patients with or without nephrectomy.

CONCLUSIONS

Although race is a determinant of access to nephrectomy, it should not be interpreted as a barrier to care, as survival was unaffected by race in patients having a nephrectomy or not. Instead, race might represent a proxy of comorbidity and life-expectancy, which represent surgical selection criteria for nephrectomy.

Colorectal cancer stage at diagnosis and area socioeconomic characteristics in New Jersey

Despite effective screening methods, research suggests consistently higher rates of late stage colorectal cancer (CRC) among persons living in low socioeconomic areas compared to those living in affluent areas. This population-based study evaluated the association between area-based socioeconomic measures (ABSMs) and CRC stage at diagnosis in New Jersey. Cases of CRC among persons 50 years and older, diagnosed from 2000-2005, were obtained from the New Jersey State Cancer Registry. Associations between census tract-level ABSMs and CRC stage at diagnosis were evaluated using logistic regression and geographic variation assessed using a spatial scan statistic. After adjusting for covariates, including individual-level health insurance, ABSMs were significantly associated with stage at diagnosis. As area socioeconomic conditions worsened, the odds of being diagnosed at a late stage increased. While increasing CRC screening services for all New Jersey populations is warranted, this study suggests that persons living in low socioeconomic areas could benefit the most from enhanced CRC education, screening efforts, and guided interventions.