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Healthcare disparities in outcomes of patients with resectable pancreatic cancer

Published:December 10, 2018DOI:https://doi.org/10.1016/j.amjsurg.2018.12.007

      Highlights

      • When offered, white patients were less likely to refuse pancreatic cancer resection than black patients.
      • Poor socioeconomic status is associated with worse outcome in pancreatic cancer.
      • Impact of race on survival is confounded by income, education, geographic location and tumor features.
      • Identifying disparities is essential to develop targeted interventions to improve outcomes.

      Abstract

      Background

      The aim of this study was to evaluate health disparities in the outcomes of patients with resectable pancreatic adenocarcinoma.

      Methods

      We retrospectively analyzed 280,935 patients from the National Cancer Data Base (NCDB), from 1998 to 2012 to compare the differences in patient characteristics, refusal of offered surgical treatment and overall survival after pancreatic adenocarcinoma resection between white vs. black patients.

      Results

      Black patients did not undergo and refused offered surgical treatment more frequently. Race and insurance were the most important factors independently associated with not receiving the offered resection. Having private insurance, Hispanic ethnic background, geographic location, higher income, residing in urban/metropolitan area and systemic treatment were independently associated with improved survival. Race was associated with overall worse survival in an unadjusted model but not in multivariable analysis. The association between race and survival was removed when adjusting for facility location, income, education, tumor size, tumor stage or systemic treatment.

      Conclusion

      Disparities exist at various levels in resectable pancreatic cancers. These findings help developing targeted interventions and quality improvement initiatives.

      Keywords

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      References

      1. 5-Year Relative Survival by Selected Primary Site, Race, Sex, and Age Group. 2017
        • Rahib L.
        • Smith B.D.
        • Aizenberg R.
        • et al.
        Projecting cancer incidence and deaths to 2030: the unexpected burden of thyroid, liver, and pancreas cancers in the United States.
        Cancer Res. 2014; 74: 2913-2921
        • Abraham A.
        • Al-Refaie W.B.
        • Parsons H.M.
        • et al.
        Disparities in pancreas cancer care.
        Ann Surg Oncol. 2013; 20: 2078-2087
        • Anaya D.A.
        • Malafa M.
        Outcome disparities in pancreatic cancer: need for improved regionalization of care.
        JAMA Surg. 2016; 151: 345-346
        • Arnold L.D.
        • Patel A.V.
        • Yan Y.
        • et al.
        Are racial disparities in pancreatic cancer explained by smoking and overweight/obesity?.
        Cancer Epidemiol Biomark Prev. 2009; 18: 2397-2405
        • Chang K.J.
        • Parasher G.
        • Christie C.
        • et al.
        Risk of pancreatic adenocarcinoma: disparity between African Americans and other race/ethnic groups.
        Cancer. 2005; 103: 349-357
        • Hayanga A.J.
        Risk of pancreatic adenocarcinoma: disparity between African Americans and other race/ethnic groups.
        Cancer. 2005; 104 (author reply 2531): 2530-2531
        • Khawja S.N.
        • Mohammed S.
        • Silberfein E.J.
        • et al.
        Pancreatic cancer disparities in African Americans.
        Pancreas. 2015; 44: 522-527
        • Siegel R.L.
        • Miller K.D.
        • Jemal A.
        Cancer statistics, 2017.
        Ca - Cancer J Clin. 2017; 67: 7-30
        • Shavers V.L.
        • Brown M.L.
        Racial and ethnic disparities in the receipt of cancer treatment.
        J Natl Cancer Inst. 2002; 94: 334-357
        • Yin D.
        • Morris C.
        • Allen M.
        • et al.
        Does socioeconomic disparity in cancer incidence vary across racial/ethnic groups?.
        Cancer Causes Control. 2010; 21: 1721-1730
        • Harper S.
        • Lynch J.
        • Meersman S.C.
        • et al.
        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.
        Am J Epidemiol. 2008; 167: 889-899
        • Bilimoria K.Y.
        • Stewart A.K.
        • Winchester D.P.
        • Ko C.Y.
        The National Cancer Data Base: a powerful initiative to improve cancer care in the United States.
        Ann Surg Oncol. 2008; 15: 683-690
        • Team RDC
        R: A Language and Environment for Statistical Computing.
        R Foundation for Statistical Computing, Vienna, Austria2016
        • Riall T.S.
        • Townsend Jr., C.M.
        • Kuo Y.F.
        • et al.
        Dissecting racial disparities in the treatment of patients with locoregional pancreatic cancer: a 2-step process.
        Cancer. 2010; 116: 930-939
        • Wray C.J.
        • Castro-Echeverry E.
        • Silberfein E.J.
        • et al.
        A multi-institutional study of pancreatic cancer in Harris County, Texas: race predicts treatment and survival.
        Ann Surg Oncol. 2012; 19: 2776-2781
        • Singal V.
        • Singal A.K.
        • Kuo Y.F.
        Racial disparities in treatment for pancreatic cancer and impact on survival: a population-based analysis.
        J Canc Res Clin Oncol. 2012; 138: 715-722
        • Murphy M.M.
        • Simons J.P.
        • Hill J.S.
        • et al.
        Pancreatic resection: a key component to reducing racial disparities in pancreatic adenocarcinoma.
        Cancer. 2009; 115: 3979-3990
        • Shah A.
        • Chao K.S.
        • Ostbye T.
        • et al.
        Trends in racial disparities in pancreatic cancer surgery.
        J Gastrointest Surg. 2013; 17: 1897-1906
        • Changoor N.R.
        • Udyavar N.R.
        • Morris M.A.
        • et al.
        Surgeons' perceptions toward providing care for diverse patients: the need for cultural dexterity training.
        Ann Surg. 2017; (epub ahead of print)
        • Halpern M.T.
        • Ward E.M.
        • Pavluck A.L.
        • et al.
        Association of insurance status and ethnicity with cancer stage at diagnosis for 12 cancer sites: a retrospective analysis.
        Lancet Oncol. 2008; 9: 222-231
        • Krzyzanowska M.K.
        • Weeks J.C.
        • Earle C.C.
        Treatment of locally advanced pancreatic cancer in the real world: population-based practices and effectiveness.
        J Clin Oncol. 2003; 21: 3409-3414
        • Loehrer A.P.
        • Chang D.C.
        • Hutter M.M.
        • et al.
        Health insurance expansion and treatment of pancreatic cancer: does increased access lead to improved care?.
        J Am Coll Surg. 2015; 221: 1015-1022
        • Shapiro M.
        • Chen Q.
        • Huang Q.
        • et al.
        Associations of socioeconomic variables with resection, stage, and survival in patients with early-stage pancreatic cancer.
        JAMA Surg. 2016; 151: 338-345
        • Kogevinas M.
        • International Agency for Research on Cancer
        Social Inequalities and Cancer.
        xxiii. International Agency for Research on Cancer, Lyon, France1997: 397
        • van Loon A.J.
        • Brug J.
        • Goldbohm R.A.
        • et al.
        Differences in cancer incidence and mortality among socio-economic groups.
        Scand J Soc Med. 1995; 23: 110-120
        • Stitzenberg K.B.
        • Sigurdson E.R.
        • Egleston B.L.
        • et al.
        Centralization of cancer surgery: implications for patient access to optimal care.
        J Clin Oncol. 2009; 27: 4671-4678
        • Belsky D.
        • Ricketts T.
        • Poley S.
        • Gaul K.
        Surgical deserts in the U.S.: counties without surgeons.
        Bull Am Coll Surg. 2010; 95: 32-35
        • Salami A.C.
        • Barden G.M.
        • Castillo D.L.
        • et al.
        Establishment of a regional virtual tumor board program to improve the process of care for patients with hepatocellular carcinoma.
        J Oncol Pract. 2015; 11: e66-e74
        • Anaya D.A.
        • Malafa M.
        Outcome disparities in pancreatic cancer: need for improved regionalization of care.
        JAMA Surg. 2016; 151: 345-346
        • Braveman P.A.
        • Cubbin C.
        • Egerter S.
        • et al.
        Socioeconomic status in health research: one size does not fit all.
        J Am Med Assoc. 2005; 294: 2879-2888
        • Pickett K.E.
        • Pearl M.
        Multilevel analyses of neighbourhood socioeconomic context and health outcomes: a critical review.
        J Epidemiol Community Health. 2001; 55: 111-122
        • Krieger N.
        • Chen J.T.
        • Waterman P.D.
        • et al.
        Geocoding and monitoring of US socioeconomic inequalities in mortality and cancer incidence: does the choice of area-based measure and geographic level matter?: the public health disparities geocoding project.
        Am J Epidemiol. 2002; 156: 471-482