Lisa Jarvis
A new analysis from researchers at the American Cancer Society suggests that the distressing disparity in outcomes for Black and white colon cancer patients could narrow if hospitals simply treated all patients with the same level of high-quality care.
The disparity in rates and deaths from colorectal cancer among Black people has been a longstanding problem in cancer care. Black individuals are 20% more likely to be diagnosed with colon cancer and 40% more likely to die from it. They’re also more likely to be diagnosed at a younger age than their white counterparts.
Many theories have been floated to explain the poorer prognosis for Black patients. Access to high-quality care has long been considered the main culprit, with various other factors potentially contributing: delayed screening, being treated at subpar facilities, health-insurance status and socioeconomic barriers to consistent care, like lack of paid sick leave or transportation to treatment.
But those issues can’t account for all of the problem. As a January report from the American Cancer Society pointed out, later diagnoses and poor survival rates for Black individuals persist across all cancers regardless of socioeconomic and insurance status.
Researchers have also looked at whether some differences exist in the biology of the tumors themselves. Recent work from the Memorial Sloan Kettering Cancer Center suggests that colorectal cancer patients of African ancestry have tumors that are less likely to respond to certain advanced treatments, like immunotherapy. Meanwhile, a mutation called APC, which for other groups is a good predictor of survival, seemed to have no effect on outcomes for Black patients.
The new ACS analysis suggests there’s more to the story — and that oncology practices need to reflect on whether they are always offering equitable care.
The nonprofit’s researchers used colon-cancer cases reported in the National Cancer Database between 2004 and 2019 to look for differences in care along the entire treatment path for Black and white patients diagnosed with early-onset colorectal cancer. “We have these very comprehensive, detailed guidelines for the type of cancer you’re diagnosed with,” says Leticia Nogueira, who led the study. The question her team asked: Are Black patients receiving care in concordance with guidelines?
The answer is no. For every stop along the road from diagnosis to treatment — from staging of their disease, surgery, radiation to chemotherapy — Black patients were less likely to receive concordant care.
In one of the most striking findings, Black colorectal cancer patients undergoing surgery to have tumors removed had far fewer lymph nodes evaluated, a step that typically determines whether they should receive chemotherapy. “It is very hard to find a reason why a patient who is under anesthesia, inside of the operating room, already undergoing surgery, would be less likely to receive this kind of guideline-concordant care,” Nogueira says.
And while some have speculated that one contributor to the disparity in colon cancer outcomes is that Black patients are being cared for at low-performing institutions, the ACS team found that, rather, they were getting lesser care at high-performing ones. Nearly a third of Black colon and rectal cancer patients were treated at teaching hospitals, which are usually known for having higher rates of concordance with, for example, lymph-node evaluation.
“We all as institutions and as a society probably need to do better in terms of bias and unconscious bias, as well as systemic and structural racism,” says Kimmie Ng, director of the colorectal-cancer center at Dana-Farber Brigham Cancer Center in Boston.
One straightforward way to begin tackling the problem: High-performing facilities should be more rigorous when evaluating their performance. That could start with looking beyond their overall quality measures to consider not only the outcomes for patients by race, but to what degree their care followed the guidelines. If differences are identified, hospitals should introduce interventions to help ensure equitable care for all.
Lisa Jarvis is a Bloomberg Opinion columnist covering biotech, health care and the pharmaceutical industry. Previously, she was executive editor of Chemical & Engineering News.
