An Underappreciated Cause of Cancer Death: Disparities in Treatment
San Francisco, CA—When cancer treatment is equal among patients, the outcomes are equal as well, “but there is not equal treatment” within the US population with cancer, according to Otis W. Brawley, MD, Chief Medical and Scientific Officer of the American Cancer Society, and Professor of Hematology, Medical Oncology, Medicine, and Epidemiology at Emory University, Atlanta.
Dr Brawley discussed cancer care disparities at the 2012 Breast Cancer Symposium. He is the author of the 2012 exposé of the healthcare system, How We Do Harm: A Doctor Breaks Ranks About Being Sick in America (St. Martin’s Press).
“When we have conversations about expensive tyrosine kinase inhibitors and mTOR inhibitors, we must remember the $2.53 trillion in healthcare costs to the US in the year 2009. In comparison, the US spent $1.1 trillion on food. We all know that the US has the highest per-capita spending, but this does not translate into longer life expectancy. We are 50th, just behind Albania, which is 49th. We spend more on healthcare, and we don’t get what we pay for,” Dr Brawley said.
The Challenge of Disparities
Despite the gargantuan healthcare budget, many patients are not receiving even adequate care, Dr Brawley stressed.
“We waste a lot of money putting it into areas where we don’t get much out of it, and we don’t put money into areas where we could save a large number of lives,” he maintained.
Disparities in treatment are a pressing problem, Dr Brawley noted. “Disparities” pertains to the concept that some populations (defined by race, socioeconomic class, and other descriptors) fare worse than others. Although there are multiple reasons, disparities often occur because of a misuse of resources, he noted.
“My concern is that equal treatment yields equal outcomes among equal patients, but there is not equal treatment,” said Dr Brawley. “And there is not enough concern about, nor emphasis on, the fact that there is not equal treatment.”
More than 2 dozen patterns-of-care studies now demonstrate that there are racial disparities in appropriate care, Dr Brawley emphasized. Differences in patterns of care by race have been documented in patients with prostate, colon, breast, and lung cancers, but the full reasons for the differences have yet to be explained.
Black women with breast cancer are less likely to receive definitive therapy, including chemotherapy, hormonal therapy, and radiotherapy or surgery, for localized disease compared with white patients (Freedman RA, et al. Cancer. 2011;117:180-189). Black women are also 40% less likely to be treated at high-quality hospitals, but not at high-volume hospitals (Keating NL, et al. Med Care. 2009;47:765-773).
These disparities may account for the gap in breast cancer mortality: 22.4 per 100,000 white women versus 31.6 per 100,000 black women, according to data from the Surveillance, Epidemiology and End Results (SEER) database. The gap has widened every subsequent year since 1980. In addition, at every stage of the disease, uninsured patients have worse survival outcomes than insured patients.
However, disparities do not occur solely along racial lines. A 2012 study of 6734 patients with breast cancer in 7 states showed that 35% of the patients did not receive adjuvant chemotherapy that was consistent with clinical practice guidelines (Wu X-C, et al. J Clin Oncol. 2012;30:142-150). Factors associated with nonstandard treatment include Medicaid status, a lack of private insurance, and living in high-poverty and low-education areas.
“We are not talking about mTOR inhibitors here. We are talking about standard adjuvant chemotherapy with the cheaper drugs,” Dr Brawley emphasized.
“There are disparities in care, no matter how you define the population and the care,” noted Dr Brawley. “Sometimes, there is more emphasis on getting a new fourth-line chemotherapy agent to market than in providing adequate, decent care to people who simply need it.”
Equal Treatment Will Yield Equal Outcomes
If patients can receive equal treatment, they can expect equal outcomes. In breast cancer trials conducted by the National Surgical Adjuvant Breast and Bowel Project, disease-free survival is similar for blacks and whites, although blacks have higher all-cause mortality, which is possibly a result of comorbidities. In addition, studies based on the SEER database show that after adjusting for treatment- and disease-related factors, comorbidities, and socioeconomic factors, the mortality rates are not significantly higher among black patients.
“Survival differences are no longer significant if you can overcome the socioeconomic problem of poverty,” Dr Brawley stated.
Paying the Cost of Treatment Disparities
It is estimated that more than 230,000 American women will be diagnosed with breast cancer in 2012, and more than 39,000 will die from it. If all women with breast cancer received optimal therapy, up to 6000 of these deaths would be averted, Dr Brawley pointed out.
Dr Brawley reiterated that a substantial proportion of patients with cancer do not receive care that is in accordance with established guidelines. These patients are not getting the inexpensive treatments that are universally accepted, such as lumpectomies with radiotherapy and even adjuvant chemotherapy.
“At the same time we are spending more and more on expensive treatments,” said Dr Brawley. “We are talking about the latest $8000-a-month drug for third-line treatment of advanced disease that prolongs survival by 3 months, while we are missing the point: if we simply did the things we currently know, and applied the technology we currently have (such as mammography screening), we have the ability to save lives.”