Racial disparity in mortality after cancer surgery persists

Last Updated: 2020-12-04

By Linda Carroll

(Reuters Health) - Disparities between Black and white patients in mortality after cancer surgery have persisted even as death rates have declined in both groups, a U.S. study finds.

In an analysis of data from more than 870,000 patients with nine cancer types, researchers found that between 2007 and 2016 the 30-day mortality rate after cancer surgery dropped slightly among both Black patients and their white counterparts, but remained higher among Black patients, according to the report published in JAMA Surgery.

"Mortality after cancer surgery is declining for both Black and white patients over time, but the mortality gap between the two groups still remains," said the study's lead author, Dr. Miranda Lam, a radiation oncologist and health services policy researcher at Brigham and Women's Hospital/Dana Farber Cancer Institute in Boston, and an assistant professor at the Harvard T.H. Chan School of Public Health.

"Improvements in mortality for both groups were from within-hospital improvements, that is improvements in outcomes within institutions, instead of from patients shifting from low- to high-quality hospitals," she noted.

"These findings provide mixed news for policymakers interested in seeing reductions in disparities in mortality after cancer surgery, given that we observed an overall decrease in mortality for both Black and White patients but no improvement in the disparity gap over time," Dr. Lam said in an email.

While more research needs to be done to understand the persistent disparity, there are some possible explanations, Dr. Lam said.

"First, we found higher rates of surgical complications in Black patients compared to White patients," she said. "Second, Black patients have increased exposure to risk factors that place them under a disproportionate burden of disease and a greater likelihood of being diagnosed at a later stage and treated by doctors at lower-volume hospitals. Finally, the disparity gap may be due to upstream and/or downstream issues from the surgery itself (i.e., late referrals which may lead to late presentation at time of surgery, failure to rescue, poor follow-up after discharge, limited resources in the community, etc.), and that different policies and intervention may be needed to address disparities in cancer surgery."

To take a closer look at racial disparities in mortality after cancer surgery Dr. Lam and her colleagues turned to several databases: The Medicare Provider Analysis and Review Files, and Medicare Inpatient Claims data were linked to the Beneficiary Denominator File and Medicare Enrollment Database. These provided patient-level variables, including basic demographic characteristics, primary causes and dates of hospitalizations, comorbidities, mortality and procedures.

The researchers also included information from the American Hospital Association annual survey and the Area Health Resources Files, which provided community level variables, including demographic and socioeconomic data, such as the median household income and the average level of education of the community in which patients lived.

Using claims data from January 1, 2007 to November 30, 2016, the researchers identified 870,929 fee-for-service beneficiaries enrolled in Medicare Part A who had a major surgical resection for colorectal, bladder, esophageal, kidney, liver, ovarian, pancreatic, lung or prostate cancer at one of 2,761 hospitals.

The 30-day mortality rate among the 7,236 Black patients in the baseline year was 4.84% as compared to 4.29% in the 96,210 white patients. In 2016, the death rate among the 5,562 Black patients was 3.81% as compared to 3.09% in the 66,204 white patients.

Overall, mortality declined 0.12% among Black patients and 0.14% among white patients during the study period.

The new study is "very interesting," said Dr. Otis Brawley, Bloomberg Distinguished Professor of Oncology and Epidemiology in the Johns Hopkins School of Medicine and the Johns Hopkins Bloomberg School of Public Health in Baltimore.

"It's fascinating, though it doesn't tell us anything I would not have expected," Dr. Brawley said. "Mortality has declined for both Blacks and whites because our attempts to improve surgery have worked and the number of small hospitals that might have been doing surgery have actually decreased because of the economy and thus patients have been pushed to bigger, high volume centers."

Another explanation for the overall improvement may be the expanded use of laparoscopic surgery, Dr. Brawley said.

The disparity can largely be explained by two factors, Dr. Brawley said: higher rates of obesity and diabetes in African American patients and less access to high quality hospitals.

While the study doesn't have information on the surgeons or hospitals patients went to, there is enough research out there now to show that Black and white patients have similar outcomes after surgery when they are at a high quality center, such as the MD Anderson Cancer Center or Walter Reed Medical Center, Dr. Brawley said. "Equal patients getting equal treatment yields equal outcomes," he added.

SOURCE: https://bit.ly/3ohEMxc JAMA Network Open, online December 3, 2020.