P. Lu1,2, R. E. Scully1, Q. Trinh2,3, A. C. Fields1, R. Bleday1, J. E. Goldberg1, A. H. Haider1,2, N. Melnitchouk1,2 1Brigham And Women’s Hospital,Department Of Surgery,Boston, MA, USA 2Center for Surgery and Public Health,Brigham And Women’s Hospital,Boston, MA, USA 3Brigham And Women’s Hospital,Department Of Urologic Surgery,Boston, MA, USA
Introduction:
Racial disparities have been shown to exist in the treatment of rectal cancers with black patients having poorer survival and less adequate treatment compared to white patients. Minority serving hospitals (MSH) provide healthcare to a disproportionately large percent of minority patients in the United States. To better understand the cause of these disparities, we examined outcomes of rectal cancer patients treated at MSH using the National Cancer Database (NCDB).
Methods:
NCDB was queried (2004-2014), and patients diagnosed with stage 2 or 3 rectal adenocarcinoma were identified. Racial case mix distribution was calculated at the institutional level and MSH were defined as those within the top decile of black and Hispanic patients. Standard of care (SOC) was defined by undergoing adequate surgery (low anterior resection, abdominoperineal resection or pelvic exenteration), chemotherapy, and radiation. A Cox proportional hazards model was used to evaluate adjusted risk of death and an adjusted logistic regression model was created for receipt of SOC. Analyses were clustered by facility.
Results:
60,855 patients were identified with stage 2 or 3 rectal adenocarcinoma. 55,727 (91.6%) patients were treated at non-MSH, and 5,128 (8.4%) were treated at MSH. Adjusting for age, gender, comorbidies, tumor stage, insurance, education, and income, black (OR 0.66 95%CI 0.55-0.80 p<0.001), white (OR 0.70 95% CI 0.61-0.80 p<0.001), and Hispanic (OR 0.68 95%CI 0.53-0.86 p<0.001) individuals were each less likely to receive SOC at MSH vs non-MSH. In unadjusted survival analysis, risk of death was significantly higher at MSH vs non-MSH for black individuals but not for white individuals (Figure 1). When adjusting for receipt of SOC, patient characteristics, and disease specific variables this difference was no longer seen (HR 1.03 95%CI 0.92-1.17 p=0.59). In adjusted analysis of the overall group, black individuals had a significantly higher risk of mortality (HR 1.20 95%CI 1.14-1.26 p<0.001) compared to white individuals. This was persistent despite inclusion of receipt of SOC in the model (HR 1.16 95%CI 1.10-1.23 p<0.001).
Conclusions:
Treatment at MSH institutions was associated with significantly decreased odds of receipt of SOC for rectal adenocarcinoma across racial groups. Survival was worse for black individuals compared to white in both unadjusted and adjusted analyses. However, in adjusted analysis there was no difference in mortality for black individuals in MSH vs non-MSH when receipt of SOC was included in the model. Further studies are needed to examine the racial disparity that persists in rectal cancer treatment, and address barriers facing MSH in providing rectal cancer SOC to all.
