City of Hope researchers have reported that Black patients have a low rate of liver resection and this is associated with lower survival among this group of patients with colorectal cancer (CRC). The study found that they were the least likely to receive chemotherapy (59% compared to 65% among white people) and had a 17% higher chance of death compared to white people, even when the researchers controlled for age, sex and comorbidities.
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 tumour board setting, meaning by a group of subspecialists. The finding potentially has broad reach considering colorectal cancer is the third leading cause of cancer-related deaths in the US (excluding some kinds of skin cancer). If detected early, about 90% of individuals survive for five years or more, according to the American Cancer Society.
"The unfortunate reality is that minorities, especially Black people, have a much lower chance of getting lifesaving cancer treatment. Health care works within a social construct, and to change health disparities, we need social change," said Dr Mustafa Raoof, surgical oncologist at City of Hope and senior author of a study, ‘Association of Race/Ethnicity With Overall Survival Among Patients With Colorectal Liver Metastasis’, published in JAMA Network Open. "These troubling statistics are the result of a disparity in access to health care. 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 underutilisation of lifesaving therapies."
Colorectal cancer death rates are almost 40% higher in Black people compared to white individuals, according to a 2020 American Cancer Society report, which attributes 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.
For the investigation, the researchers conducted a retrospective cohort study of 16,382 adult patients in the California Cancer Registry with synchronous colorectal liver metastases (CRLM) from January 2000 to December 2012. They found that Black patients had the lowest median survival (11 months) vs Asian (14 months), Hispanic (14 months), Middle Eastern (18 months) and White (12 months) patients. In a comparison with White and Hispanic patients, Black patients were the least likely to receive chemotherapy (59% vs 65% (White patients) vs 68% (Hispanic patients); p< .001) or undergo liver resection (6.2% vs 10.3% (White patients) vs 9.5% (Hispanic patients); p<.001).
After controlling for age, sex, comorbidities and extrahepatic metastasis, Black patients had a 17% higher hazard of death compared with White patients (p<.001). Among patients who underwent liver resection for CRLM, the researchers reported that there was no difference in survival between Black and White patients (p=0.84).
The City of Hope study lays the foundation for future work focusing on the specific barriers that Black patients face in getting lifesaving therapies such as liver resection.
"The decreased health outcomes in Black patients could be attributed to factors such as 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 childcare during therapy," said Dr Lucas Thornblade, a City of Hope surgical oncology fellow and first author of the study.
The rate of liver resection in the US is only about 10%, but that percentage is about 40% at City of Hope, said Dr Yuman Fong, the Sangiacomo Family Chair in Surgical Oncology at City of Hope and co-author of the study.
"There is a vast under-utilization of liver resection as a potentially curative treatment for colorectal liver metastases," said Fong. "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 five years or more, according to National Cancer Institute data.
The Centers for Disease Control and Prevention recommends that everyone age 50 or older get screened for colorectal cancer. Yet, due to their higher risk, Black people should start getting screened for colorectal cancer at age 45, added Raoof, citing a recommendation made by the American College of Gastroenterology.
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