Colorectal cancer is more prevalent among Black people, a group with the highest rates of death for an illness that is curable if caught early. “The unfortunate reality is that minorities, especially Black people, have a much lower chance of getting life-saving cancer treatment. Health care works within a social construct, and to change health disparities, we need social change,” said Mustafa Raoof, MD, a surgical oncologist at City of Hope and senior author of a study published in JAMA Network Open.1
Mustafa Raoof, MD
City of Hope researchers retrospectively looked at the data of 16,382 adult patients in the California Cancer Registry and found that Black patients were the least likely to receive chemotherapy (59% compared with 65% among White people). They also had a 17% higher chance of death than did White people, even when the scientists controlled for age, sex, and comorbidities.
“These troubling statistics are the result of a disparity in access to health care,” Dr. Raoof said. “We observed that if Black people with metastatic colorectal cancer had access to subspecialists with expertise in liver resection, they would not experience higher numbers of unnecessary deaths due to underutilization of life-saving therapies.”
Costly Delays in Treatment
The City of Hope study lays the foundation for future work focusing on the specific barriers that Black patients face in receiving life-saving therapies such as liver resection. “The decreased health outcomes in Black patients could be attributed to factors such as a lower rate of referral to cancer specialists, late detection of colorectal cancer metastases, and patient-reported barriers, including fear of cancer and its treatment, costs, and the burdens of transportation and child care during therapy,” said Lucas Thornblade, MD, a City of Hope surgical oncology fellow and first author of the study.
Lucas Thornblade, MD
The study suggests a future benchmark for quality care: All patients with colorectal cancer that has spread to the liver, regardless of race, should be evaluated for surgery by a liver surgeon in the office or tumor board setting, meaning by a group of subspecialists. The finding has a potentially broad reach, considering that colorectal cancer is the third leading cause of cancer-related deaths in the United States (excluding some types of skin cancer). If the cancer is detected early, about 90% of individuals survive for 5 years or more, according to the American Cancer Society.
The rate of liver resection in the United States is only about 10%, but that percentage is about 40% at City of Hope, said Yuman Fong, MD, the Sangiacomo Family Chair in Surgical Oncology at City of Hope and coauthor of the study. “There is a vast underutilization of liver resection as a potentially curative treatment for colorectal liver metastases,” Dr. Fong said. “This missed opportunity is even more common for Black patients than for the general population.” In fact, Black people are more likely to be diagnosed with advanced disease: only 10.5% survive 5 years or more, according to National Cancer Institute data.
Higher Incidence of Risk Factors
The Centers for Disease Control and Prevention recommends that everyone aged 50 or older undergo colorectal cancer screening. Yet, due to their higher risk, Black people should start such screening at age 45, Dr. Raoof said, citing a recommendation made by the American College of Gastroenterology.
Colorectal cancer death rates are almost 40% higher in Black people than in White individuals, according to a 2020 American Cancer Society report. This report attributed the disparity to socioeconomic status and complex risk factors such as smoking, obesity, and prolonged time until care following a positive a colorectal screening test.
“There is a vast underutilization of liver resection as a potentially curative treatment for colorectal liver metastases. This missed opportunity is even more common for Black patients than for the general population.”— Yuman Fong, MD
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Tamra Milner, a 39-year-old patient at City of Hope with stage IV colorectal cancer that metastasized to her liver, said she feels race is the reason her first doctor in Las Vegas told her she had only 6 months to live. That was more than a year ago. “I don’t feel I got the care I should’ve received there because I’m Black,” Ms. Milner said. “He saw me as a number and plugged me into the usual statistical outcomes. He didn’t take into consideration that, other than my cancer diagnosis, I’m an active and healthy 39-year-old.” Ms. Milner underwent liver surgery in late April and is scheduled for colorectal surgery.
DISCLOSURE: For full disclosures of all study coauthors, visit jamanetwork.com.
1. Thornblade LW, Warner S, Melstrom L, et al: Association of race/ethnicity with overall survival among patients with colorectal liver metastasis. JAMA Network Open. September 9, 2020 (early release online).