Combatting Cancer Surgery Disparities Due to Racial-Economic Segregation

Muhammad Talha Waheed, MD

City of Hope National Medical Center in Duarte, California

Racial-economic residential segregation has demonstrated a disproportionate impact on cancer-related mortality and access to surgery for patients who live in predominantly Black and poor areas, according to findings from a retrospective analysis of the California Cancer Registry presented at the 2024 Society of Surgical Oncology Annual Meeting (SSO). These findings may, in turn, inspire future policies to help mitigate these disparities and yield more equitable access and quality of care for all patients, according to lead study author Muhammad Talha Waheed, MD.

Waheed, a research fellow in the Department of Surgical Oncology at City of Hope National Medical Center in Duarte, California, spoke with CancerNetwork^® about the methodology of his research and the socioeconomic factors contributing to worse accessibility, timeliness, and appropriateness of anti-cancer therapy for patients in disadvantaged areas.

Compared with patients who lived in White and wealthy majority areas, those who resided in Black and poor majority locations were more likely to be diagnosed during advanced disease stages, receive care that was not in accordance with various treatment guidelines, and have worse overall survival (OS) outcomes. Looking ahead, Waheed said that he would like to assess whether similar disparities exist in states outside of California and share his findings with policymakers who may create legislature intended to alleviate the inequities observed in disadvantaged areas.

CancerNetwork: Can you discuss how racial segregation has been associated with cancer-related morbidity? What historical data or experiences have illustrated this?

Waheed: Structural racism in the United States is largely a result of historically racist residential and economic policies—for example, Jim Crow laws or redlining—which resulted in a special concentration of minorities into certain geographical areas. This racial segregation further led to an unequal divide of resources and opportunities, which then translated into worse morbidity for these patients. There are several studies that have shown disparate access and worse perioperative morbidity and mortality for these patients, especially for the ones who are living in these disadvantaged or Black and poor majority areas. [These patients] also had higher travel distances to seek care, and they had worse perioperative complications.

We know about this perioperative morbidity and mortality, but what we do not know is the long-term impact on OS for patients who are living in these disadvantaged or Black and poor majority areas. That’s what we’ve tried to explore here.

How did you decide to focus on patient-level accessibility, timeliness, and appropriateness of cancer treatment in your study?

These 3 [factors] are the benchmarks of cancer care. As for the patient level, earlier work has been focused on the geographical level or zip code level, but granular patient-level outcomes were not known. For accessibility, we looked at whether these patients underwent emergent or elective admissions. We also looked at whether they were going to Commission on Care [COC]–accredited hospitals or National Cancer Institute [NCI]–designated cancer centers. For timeliness, we looked at 2 different time points. By time points, we mean from the time of diagnosis to the initiation of any therapy. At 2 weeks, this is a surrogate for "VIP treatment," you could say. We also looked at 4 weeks, by which most of these patients should have initiated some sort of therapy after their diagnosis. In terms of appropriateness, or what we called guideline-concordant cancer care, we defined them using tumor-specific National Comprehensive Cancer Network [NCCN] guidelines, or any major, practice-changing trials that were there. The trials mainly included surgery for local or locoregional disease, or surgery plus chemotherapy for local or locoregional disease for some of these cancers.

What were the key findings from your study?

In terms of access, we saw that patients who were living in disadvantaged areas were Black and poor majority areas. I would like to emphasize that the way we stratified our analysis was that we were looking at any patient of any race or ethnicity living in these areas. It was not just Black and poor patients, but patients who were residing in areas that are Black and poor majority areas. We saw that patients who were living in these areas had a higher stage of disease at diagnosis; they were not getting diagnosed earlier. They were more likely to undergo emergent surgery, which tells us that they were not having good referrals or good access to primary care, where we’re picking up the disease earlier and sending them for elective surgery for that matter. They were also less likely to initiate any sort of therapy within 2 or 4 weeks of diagnosis. We saw that these patients had less access to COC-accredited institutions, they were less likely to undergo care in NCI–designated cancer centers, and they were less likely to undergo care in teaching institutes.

Then comes the appropriateness or the guideline-concordant care part. We saw notable differences; these patients were less likely to receive surgery for stage I through III lung, esophageal, or colorectal cancers. They were less likely to get surgery and chemotherapy for stage I to III pancreatic and stage II to III lung and gastric cancers. They were less likely to receive liver ablation or resection for colorectal liver metastasis. We saw that for all these cancers, patients who were living in privileged or White and wealthy majority areas were likely to have a better median OS. Across the band, we reported better findings for patients who were living in White and Wealthy majority areas.

What surprised you from the analysis?

The most surprising finding from our study was from the state-specific or stage-stratified analysis that we did. It showed that, first, patients who were living in disadvantaged areas, which were the Black and poor majority areas, were being diagnosed at an advanced stage; they were being diagnosed late. Even when they were being diagnosed earlier, they had higher mortality, which we believe was partly because we found [these patients] getting lesser surgery for stage I to III disease for some of these cancers.

Secondly, the way we stratified our analysis was that we divided all these patients into quintiles. Q1 was the lowest quintile, which we regarded as the Black and poor majority areas or the disadvantaged areas. Then there is Q2, Q3, Q4, and then Q5. Q5 represents the White and wealthy majority areas, or what we call the privileged areas. What we saw was a dose-dependent effect on mortality. When you move from Q1 to Q5, the mortality decreases for any of these cancers. We see that patients who were living in Q2 areas had better survival than the Q1 patients, those who were living in Q3 areas had better survival than Q1 and Q2, and so on. This was an interesting finding that we saw.

What are the next steps following this analysis?

This dataset focused on the California Cancer Registry, so it just applied to patients living in California. It’s hard to generalize these findings to other states and the United States overall. It would be worthwhile to look at these findings using some national datasets to see what trends lie there. Moreover, using this dataset, we have previously reported on disparate access, morbidity, and mortality based on insurance status. Moving forward, it’ll be good to maybe combine insurance status and racialized economic segregation and see what lies there.

How might these findings be applied to clinical practice?

This study highlights the issues that are on the systemic level and brings forward the impact of very longstanding racist policies. It’ll be hard to do anything each year to address these issues. The study shows the zip codes, areas, and disease sites that are being affected the most, and it sheds light on the mechanism that is driving these disparate survivals. That was the biggest question. It’s easier to find this disparate access and mortality, but what are the mechanisms that are driving these differences?

These are important points that we need to focus on. It provides the framework for the state- and federal-level policies to prioritize and target these areas, the disease sites, and the accessibility, timeliness, and appropriateness of cancer treatment. These patients residing in disadvantaged areas should have equal access and quality of cancer care. We will share these findings with stakeholders and policymakers in California. They can maybe use this as a guiding principle and make some policies.

Reference

Waheed MT, Sullivan KM, Haye S, et al. Impact of racialized residential segregation on guideline concordant cancer care and survival. Presented at the Society of Surgical Oncology (SSO) 2024 Annual Meeting; March 20 – 23, 2024; Atlanta, GA; abstract E126.