Does DoD Have Secret to Ending Racial Disparities in Cancer?

Nick Mulcahy

March 21, 2013

Washington, DC — Black and white patients with pancreatic cancer in the Department of Defense (DoD) healthcare system received similar treatments and have a similar median overall survival, according to a retrospective study presented here at the Society of Surgical Oncology (SSO) 66th Annual Cancer Symposium.

"In the equal-access DoD healthcare system, racial disparities among patients treated for pancreatic cancer were not observed," said presenter Steve Sukhyung Lee, MD, a surgical oncology fellow at the University of Texas M.D. Anderson Cancer Center in Houston. He is also an active duty Army officer.

Dr. Lee explained that the DoD system provides healthcare for all active duty military personnel and retirees with at least 20 years of service. Beneficiaries of this system have "equal access to healthcare resources," write Dr. Lee and his coauthors in their study abstract.

Thus, whether an individual is a private or a general, black or white, the system provides the "same generous comprehensive insurance coverage, with unlimited access to care," they note.

"For active duty, it is all free. For retirees, the monthly premium is less than $50. DoD healthcare usually has no copays," Dr. Lee told Medscape Medical News in an interview.

He and his colleagues used the DoD's cancer registry to find data on 851 white and 157 black patients diagnosed with pancreatic cancer from 1993 to 2007. The characteristics of the 2 groups were balanced, except that the white patients were, on average, older (65 vs 62 years; P < .01).

For all stages of pancreatic cancer, there was a nonsignificant difference in median survival for black and white patients (6 vs 5 months; P = .17).

For locoregional-stage pancreatic cancer, the rates of surgery and adjuvant therapy were similar in the 2 groups (about 50% for each treatment). For distant-stage pancreatic cancer, comparable percentages of black and white patients received chemotherapy (46% vs 40%).

This is 1 of 5 studies by DoD researchers to examine cancer outcomes in black and white patients enrolled in their system, Dr. Lee said.

Previous studies of patients with breast, colon, lung, and thyroid cancers treated in the DOD system had the same findings: outcomes were equal in black and white patients.

Working with no budget, Dr. Lee and his colleagues might have found a Holy Grail that equalizes cancer outcomes in black and white patients. "If you have comprehensive, universal healthcare, it looks like racial disparities are not observed," said Dr. Lee.

Dr. Lee explained that the DoD system is a unique setting in which to examine racial disparities, and clarified that the system is distinct from the Veterans Administration (VA).

The VA system is for military personnel who are no longer in the service and who did not serve long enough (20 years) to qualify for the DoD system. The VA also takes care of wounded veterans and all low-income veterans who cannot afford health insurance.

The DoD coverage is unrelated to disability or income, said Dr. Lee, who suggested that its patient population is inherently more balanced.

However, a considerable limitation of this study is that patient population. An all-military population is likely healthier, because we have to "maintain certain physical aspects" and we might "follow doctors' recommendations better because we are all trained to follow orders," he explained.

In other healthcare systems, equal access might not translate into the same results for pancreatic cancer, Dr. Lee pointed out. For instance, studies of Medicare, which is theoretically an equal-access insurer, have shown racial disparities in pancreatic cancer treatment.

"Black patients received less surgery and chemotherapy for locoregional pancreatic cancer [than white patients] in SEER–Medicare database studies," Dr. Lee said.

Multiple factors, including provider bias, patient bias, and communication problems, are likely responsible for that outcome, he added.

Social Not Biologic Factor

This study suggests that a social factor — access to care — and not race (and whatever biology might be associated with it) is the key to pancreatic cancer outcomes.

But the national discussion about cancer disparities and the funding for related research has shortchanged social factors. It has been dominated by the "biologic perspective," according to Quyen Chu, MD, director of surgical oncology at the Feist-Weiller Cancer Center in Shreveport, Louisiana.

At least that was the case in breast cancer, he told Medscape Medical News in 2009.

Dr. Chu was the driving force behind a rare randomized controlled trial that compared survival in black and white women (with operable breast cancer) who were of similar socioeconomic status.

The 5-year overall survival rate was 81% for black women and 84% for white women (P = .23).

The result was surprising because the researchers expected — and found — biologic differences between the black and white women (such as age, tumor grade, and hormone-receptor status) that favored a better outcome for white women.

But that study indicated that an egalitarian healthcare can balance the scales.

"We demonstrated that biologic differences can be mitigated by providing equal care and equal access," Dr. Chu said at the time, explaining that patients were treated without regard to financial status at the public Louisiana State University Health Sciences Center in Shreveport.

There is plenty of evidence that access to care contributes to racial disparities in healthcare, said Dr. Lee.

"Racial minorities are less likely to have health insurance and are less likely to receive quality healthcare," he told the SSO audience.

Outside of the DoD system, much needs to be done, Dr. Lee said. In the United States, black patients with pancreatic cancer have a shorter median overall survival than white patients. They also receive surgical and medical evaluation, surgical resection, and adjuvant therapy for their pancreatic cancers less frequently, he noted.

Dr. Lee has disclosed no relevant financial relationships.

Society of Surgical Oncology (SSO) 66th Annual Cancer Symposium: Abstract 63. Presented March 8, 2013.