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Overall mortality rates after cancer surgery have improved in recent years, but the mortality gap between Black and White patients persists. So conclude the authors of a 10-year cross-sectional study of more than 870,000 procedures that was published on December 3 in JAMA Network Open.
The study covered the period from January 1, 2007, to November 30, 2016. During that time, the 30-day risk-adjusted, all-cause US mortality rate after cancer surgery decreased by 0.12% per year for Black patients and by 0.14% per year for White patients. The improvements were mainly attributable to within-hospital vs between-hospital mortality differences.
However, no significant difference was seen in the mortality rate gap between Black and White patients. The racial difference was 0.55% in 2007–2008 and 0.73% in 2015–2016, the authors report. There was only a 0.03% change per year during the study period.
“These findings suggest that although interventions, policies, and advancements in technology have improved mortality for all patients, they have not targeted disparities between Black and White patients,” note the authors, led by Miranda B. Lam, MD, MBA, of Brigham and Women’s Hospital and Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.
They note that their findings contrast with recent reports of a reduction in mortality and in the disparity gap for noncancer surgeries.
The failure of “whatever interventions were put into place to improve surgical outcomes” underscores the importance of expanding perspective and the scope of such efforts, say Michelle C. Salazar, MD, and Cary P. Gross, MD, of the Yale School of Medicine, New Haven, Connecticut, in an accompanying editorial.
“As a means of studying racial disparities, it is clear that the biomedical model has run its course, ” they continue. “Focusing on purely biomedical factors has resulted in major blind spots that have kept us from recognizing the importance of the social determinants of health, such as racism.
“We need to exchange the narrow biomedical lens that hospitals and health systems have used for so long to evaluate and improve health care for an equity lens that allows for assessment and amelioration of factors that contribute to disparities,” the editorialists comment.
Details of the Findings
For their study, Lam and colleagues analyzed data from Medicare (participants were fee-for-service Medicare Part A beneficiaries), the American Hospital Association survey, and from community-level studies. They examined cancer surgery–specific mortality for nine common cancer types: colorectal, bladder, esophageal, kidney, liver, ovarian, pancreatic, lung, and prostate.
At baseline, mortality rates were higher among Black patients than White patients after surgery for prostate, esophageal, pancreatic, lung, kidney, and colorectal cancer; the differences were significant only for prostate, lung, and colorectal surgery.
In 2015–2016, mortality rates continued to be higher for Black patients for all the types of surgery examined except surgery for esophageal cancer. The difference was significant only for those who underwent colorectal cancer surgery.
Over time, mortality decreased for all patients across the nine cancer types except among Black patients who underwent prostate cancer surgery. They experienced a 0.01% increase per year, but the disparity gaps did not change significantly.
“Understanding why overall cancer surgery mortality has decreased while the mortality gap has not closed may provide further insights into how to provide better care for all patients,” the authors conclude.
The study was partially funded by a National Institutes of Health/National Institute on Minority Health and Health Disparities grant. Lam and colleagues have disclosed no relevant financial relationships. Editorialist Gross has received grants from the National Comprehensive Cancer Network (provided by Pfizer and AstraZeneca) and Johnson & Johnson and personal fees from Flatiron Inc. for travel/speaking outside the submitted work.
JAMA Netw Open. Published online December 3, 2020. Full text, Editorial
Sharon Worcester is a reporter for MDedge News, part of the Medscape Professional Network.
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