In a study published in the Journal of Clinical Oncology Practice, Herb et al investigated racial and ethnic disparities in the receipt of guideline-concordant care among older adults with pancreatic cancer. Using data spanning 15 years, the researchers examined whether differences in treatment contributed to survival disparities, with a particular focus on Black and Hispanic patients. The results showed that, despite universal insurance coverage, significant disparities in the delivery of evidence-based care persisted, especially for patients with early-stage disease.
Study Details
The investigators used the SEER–Medicare database to identify patients aged 65 and older diagnosed with incident, pathologically confirmed pancreatic ductal adenocarcinoma between 2004 and 2019. Patients were categorized as non-Hispanic White (NH-White), non-Hispanic Black (NH-Black), or Hispanic. Other races were excluded because of low sample size.
Guideline-concordant care was defined according to stage at diagnosis, based on National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology (NCCN Guidelines®). For stage I or II disease, guideline-concordant care included surgery and chemotherapy with or without radiation; for stage III disease, chemotherapy with or without surgery or radiation; and for stage IV disease, chemotherapy with or without radiation. The primary endpoint was receipt of guideline-concordant care. Secondary outcomes included the time to first treatment and overall survival. In the primary analysis, multivariable logistic regression was used to identify racial and ethnic disparities associated with guideline-concordant care. The Oaxaca-Blinder decomposition model was used in a secondary analysis to assess the relative contribution of measured and unmeasured factors to discernible racial differences in care.
Key Results
The final cohort consisted of 12,772 patients (10,915 NH-White, 992 NH-Black, and 865 Hispanic). Overall, 56.3% of patients received stage-specific guideline-concordant care. The likelihood of receiving such care varied significantly by race. For patients with stage II or III disease, NH-Black patients had substantially lower odds of receiving guideline-concordant therapy compared with NH-White patients (42.9% vs 29.2% for stage II disease, 78% vs 68.6% for stage III disease). The odds were lower for both NH-Black and Hispanic patients, respectively, after statistical adjustment (adjusted odds ratio [aOR] = 0.58, 95% confidence interval [CI] = 0.47–0.73, P < .01; aOR = 0.79, 95% CI = 0.63–0.99, P = .04). No appreciable differences were seen for patients with stage IV disease.
The researchers also identified significant differences in treatment delay and omission. NH-Black patients experienced the longest time to first treatment and the highest percentage receiving no treatment compared with the rest of the cohort across all stages.
On multivariable survival analysis, receipt of guideline-concordant care was associated with significantly improved outcomes (hazard ratio = 0.73, 95% CI = 0.70–0.76). However, disparities in survival remained between NH-Black and NH-White patients even after accounting for guideline-concordant care. According to the investigators, this suggests that additional factors may contribute to inequities in access to care and overall survival, including functional status, provider bias, and comorbidities.
The authors concluded: “Approximately half of an insured population with [pancreatic cancer] receives [guideline-concordant care], highlighting a need to improve multidisciplinary access and treatment. Black-White racial disparities in receipt of [guideline-concordant care] remain prevalent, particularly for early-stage disease. The unmeasured factors driving treatment disparities warrant prospective studies.”
Joshua Herb, MD, MSCR, of the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, is the corresponding author of the Journal of Clinical Oncology Practice article.
Disclosure: This study was funded by the California Department of Public Health, the Centers for Disease Control and Prevention’s National Program of Cancer Registries, and the National Cancer Institute. For full disclosures of all study authors, visit ascopubs.org.
