V. Patel1, M. Liu2, R. Snyder3, A. Loehrer4, A. Haynes1 1Dell Medical School, Austin, TX, USA 2Harvard Medical School, Boston, MA, USA 3The University of Texas MD Anderson Cancer Center, Houston, TX, USA 4Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
Introduction: Racial and ethnic differences in declining potentially curative cancer surgery has been attributed to inequities in access to care and mistrust of healthcare systems, among other factors. While federal policies have targeted health inequities over the past two decades, it is unknown whether rates of declined surgery among minoritized populations have changed. The objective of this study was to assess trends in racial and ethnic differences in declined cancer surgery in the United States over the past 20 years.
Methods: We performed a population-based cohort study using the US Surveillance, Epidemiology, and End Results Program. We included individuals diagnosed with the 15 highest mortality cancers in the US between 2000 and 2019, who had non-metastatic disease and were recommended for surgery. The exposure of interest was race and ethnicity (Non-Hispanic Asian, Non-Hispanic Black, Hispanic, or Non-Hispanic White). The primary outcome was declined surgery, defined as surgical intervention that was specifically recommended by the physician and declined by the patient or surrogate decision-maker. Annual risk-adjusted rates of declined surgery were estimated for each racial and ethnic group using a mixed-effects logistic regression model with the following parameters: age, sex, primary site, stage, income, rurality, state random effects, and a (race and ethnicity × year of diagnosis) interaction term. Marginal standardization was used to estimate risk-adjusted rates and their within-group and between-year differences
Results: The study included 2,740,129 individuals with non-metastatic cancer (median [IQR] age, 65 [54-74] years). Of patients, 7.6% identified as Asian, 8.8% Black, 10.6% Hispanic, and 73.0% White. Black patients had the highest rates of declined surgery (2.4% [95%CI, 2.0%-2.8%] in 2000 and 2.3% [95%CI, 1.9%-2.6%] in 2019), while White patients had the lowest rates (1.0% [95%CI, 0.9%-1.1%] in 2000 and 1.2% [95%CI, 1.1%-1.4%] in 2019). From 2000 to 2019, racial and ethnic differences in declined surgery did not change significantly. When stratified by cancer site, there were significant reductions in the Black-White disparity in declination rates for 4 of 15 cancer sites (esophageal, pancreatic, lung, and kidney), though the Black-White disparity for all cancer sites remained statistically significant in 2019 (P<.01).
Conclusions: In this national study, patients from racial and ethnic minoritized groups were more likely to decline surgical intervention for potentially curable malignancies. This disparity has largely persisted over the past two decades. Understanding and addressing reasons for declining recommended surgical therapy will be critical to achieve equitable oncologic outcomes.
