Decades of Research Fail to Resolve Disparities in Gastrointestinal Cancer Care

Laird Harrison

January 27, 2022

Men and White people receive better treatment for gastroesophageal cancer than women, Blacks, and Latinos despite years of studies highlighting disparities in care, researchers say.

The problem is complex because it stems from both biological and socioeconomic factors, but some signs of improvement are beginning to show, said Nathaniel R. Evans III, MD, a professor of surgery at Thomas Jefferson University in Philadelphia.

"Repeatedly, we see that, although we know how patients should be treated, there are oftentimes subsets of patients who don't receive that same level of care," said Evans in a general session talk at the American Society of Clinical Oncology Gastrointestinal Cancers Symposium.

Black patients with esophageal cancer are 38% more likely to die from the condition than White patients, he said, citing a 2013 study (Ann Surg Oncol. 2013 doi: 10.1245/s10434-012-2807-3). For Latino patients, mortality is 20% higher than for White patients.

The difference can mostly be explained by the rate of esophagectomy, which is 52% lower for Black patients and 29% lower for Latino patients, compared with White patients, the study found.

Besides race and gender, insurance status also influences who gets surgery, Evans said, citing data from the National Cancer Database. Black patients are less likely to get surgery and more likely to die at all stages and histologies, he said. They wait longer for treatment and are more likely to receive no treatment at all.

Women also suffer from disparities, said Anna Dorothea Wagner, MD, head of the gastrointestinal cancer clinic at Lausanne University Hospital in Lausanne (Switzerland), who spoke at the symposium with Dr Evans.

Seventy-five percent of men with esophageal and gastric adenocarcinoma get curative treatments, compared with only 60% of women, Wagner said, citing a 2020 study on which she is an author. Women are more likely to get palliative care. As a result, 30% of women survive the condition for only 5 years compared to 34% of men, she said. "At the moment we don't know whether this is due to either patient preferences or cognitive or bias of physicians."

Disparities in Treatment Outcomes Because of Biological Differences

For women, some disparities also arise out of clear biological differences, Wagner said. Sex hormone signaling affects cancer susceptibility, and sex-biased gene expression signatures have been detected in multiple cancer types.

Women with poorly differentiated and signet-cell pathology are less likely to survive their cancer than men with the same histology, she said.

Many studies have shown that chemotherapy is more toxic to women than men without being more efficacious, she added. This suggests that the optimal doses might be different for women and men.

Responding to a question from the audience, Wagner said more research is needed on transgender patients to understand how these factors affect them.

Evans attributed the racial and ethnic disparities to some combination of differential histology, stage at diagnosis, access to care, socioeconomics, and inherent bias.

"The problem is not new," Evans said. He described studies that found disparities in the 1970s. "But the good news is that things do seem to be getting better."

Between 2000 and 2011, the number of esophagectomies being performed at high-volume hospitals increased, he said. The overall mortality after esophagectomy has consequently decreased over this time, and the gap in this rate between White and Black people has closed, he said. "Specialization and centralization clearly improve outcomes for certain surgical procedures."

To address the problem everyone should acknowledge the disparities, particularly in the access to surgery. "I think one of the best tools we have to try to address the disparity is education, both for patients and providers," Evans said.

Care teams must become more diverse and culturally competent to combat longstanding distrust and improve communication, he said.

In December, ASCO announced an "action plan" to address equity, diversity and inclusion in cancer care. The organization promised to improve clinical trial eligibility, and train researchers about inherent bias in order to make the trials more representative of the cancer population.

It vowed to increase participation of underrepresented groups in its professional development programs and leadership roles, and educate its members about equity. And, it resolved to provide resources to providers so they could advocate for better quality of care, especially in rural and disadvantaged settings.

Wagner disclosed relationships with Alligator Bioscience, BMS, Dragonfly Therapeutics, Lilly, Merck KGaA, MSD Oncology, Servier/Pfizer, and Abbvie. Evans disclosed relationships with Bristol Myers Squibb Foundation and Intuitive Surgical.

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