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IMPROVING PATIENT CARE

Racial Disparities in Colon Cancer Survival: A Matched Cohort StudyRacial Disparities in Colon Cancer Survival

Jeffrey H. Silber, MD, PhD; Paul R. Rosenbaum, PhD; Richard N. Ross, MS; Bijan A. Niknam, BS; Justin M. Ludwig, MA; Wei Wang, PhD; Amy S. Clark, MD; Kevin R. Fox, MD; Min Wang, MHS; Orit Even-Shoshan, MS; and Bruce J. Giantonio, MD
[+] Article, Author, and Disclosure Information

From Center for Outcomes Research, The Children's Hospital of Philadelphia; Abramson Cancer Center, University of Pennsylvania; Perelman School of Medicine, University of Pennsylvania; The Wharton School, University of Pennsylvania; The Leonard Davis Institute of Health Economics, University of Pennsylvania; and The Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.

Acknowledgment: The authors thank Traci Frank, AA; Hong Zhou, MS; and Alexander Hill, BS (Center for Outcomes Research, The Children's Hospital of Philadelphia), for their assistance with this research.

Grant Support: By the Agency for Healthcare Research and Quality (grant R01 HS 018355) and the National Science Foundation (grant NSF SBS 1260782).

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-0900.

Reproducible Research Statement:Study protocol: Available from Dr. Silber (e-mail, silber@email.chop.edu). Statistical code: The code was written in SAS and R. For more information about the statistical code, contact Dr. Silber (e-mail, silber@email.chop.edu). Data set: SEER-Medicare colon cancer data can be acquired from the National Cancer Institute at http://appliedresearch.cancer.gov/seermedicare.

Requests for Single Reprints: Jeffrey H. Silber, MD, PhD, Center for Outcomes Research, The Children's Hospital of Philadelphia, 3535 Market Street, Suite 1029, Philadelphia, PA 19104; e-mail, silber@email.chop.edu.

Current Author Addresses: Dr. Silber: The Nancy Abramson Wolfson Professor of Health Services Research, Center for Outcomes Research, The Children's Hospital of Philadelphia, 3535 Market Street, Suite 1029, Philadelphia, PA 19104.

Dr. Wang, Mr. Ross, Mr. Niknam, Mr. Ludwig, Ms. Wang, and Ms. Even-Shoshan: Center for Outcomes Research, The Children's Hospital of Philadelphia, 3535 Market Street, Suite 1029, Philadelphia, PA 19104.

Dr. Rosenbaum: The Robert G. Putzel Professor, Department of Statistics, The Wharton School, University of Pennsylvania, 473 Jon M. Huntsman Hall, 3730 Walnut Street, Philadelphia, PA 19104-6340.

Dr. Clark: Rena Rowan Breast Center, Abramson Cancer Center, Perelman Center for Advanced Medicine, 3 West Pavilion, 3400 Civic Center Boulevard, Philadelphia, PA 19104.

Dr. Fox: The Mariann T. and Robert J. MacDonald Professor in Breast Cancer Care Excellence, Perelman Center for Advanced Medicine, 3 West Pavilion, 3400 Civic Center Boulevard, Philadelphia, PA 19104.

Dr. Giantonio: Associate Professor of Medicine, Abramson Cancer Center, Perelman Center for Advanced Medicine, University of Pennsylvania, 4 West Pavilion, 3400 Spruce Street, Philadelphia, PA 19104.

Author Contributions: Conception and design: J.H. Silber, P.R. Rosenbaum, K.R. Fox, B.J. Giantonio.

Analysis and interpretation of the data: J.H. Silber, P.R. Rosenbaum, R.N. Ross, B.A. Niknam, J.M. Ludwig, W. Wang, A.S. Clark, M. Wang, O. Even-Shoshan, B.J. Giantonio.

Drafting of the article: J.H. Silber, P.R. Rosenbaum, B.A. Niknam, A.S. Clark, B.J. Giantonio.

Critical revision of the article for important intellectual content: J.H. Silber, P.R. Rosenbaum, B.A. Niknam, J.M. Ludwig, A.S. Clark, K.R. Fox, B.J. Giantonio.

Final approval of the article: J.H. Silber, P.R. Rosenbaum, B.A. Niknam, W. Wang, A.S. Clark, K.R. Fox, B.J. Giantonio.

Provision of study materials or patients: J.H. Silber, K.R. Fox.

Statistical expertise: J.H. Silber, P.R. Rosenbaum, R.N. Ross, W. Wang.

Obtaining of funding: J.H. Silber, P.R. Rosenbaum, O. Even-Shoshan.

Administrative, technical, or logistic support: J.H. Silber, B.A. Niknam, M. Wang, O. Even-Shoshan.

Collection and assembly of data: J.H. Silber.


Ann Intern Med. 2014;161(12):845-854. doi:10.7326/M14-0900
Text Size: A A A

Background: Differences in colon cancer survival by race are a recognized problem among Medicare beneficiaries.

Objective: To determine to what extent the racial disparity in survival is due to disparity in presentation characteristics at diagnosis or disparity in subsequent treatment.

Design: Black patients with colon cancer were matched with 3 groups of white patients: a “demographic characteristics” match controlling for age, sex, diagnosis year, and Survey, Epidemiology, and End Results (SEER) site; a “presentation” match controlling for demographic characteristics plus comorbid conditions and tumor characteristics, including stage and grade; and a “treatment” match, including presentation variables plus details of surgery, radiation, and chemotherapy.

Setting: 16 U.S. SEER sites.

Patients: 7677 black patients aged 65 years or older diagnosed between 1991 and 2005 in the SEER–Medicare database and 3 sets of 7677 matched white patients, followed until 31 December 2009.

Measurements: 5-year survival.

Results: The absolute difference in 5-year survival between black and white patients was 9.9% (95% CI, 8.3% to 11.4%; P < 0.001) in the demographic characteristics match. This disparity remained unchanged between 1991 and 2005. After matching for presentation characteristics, the difference decreased to 4.9% (CI, 3.6% to 6.1%; P < 0.001). After additional matching for treatment, this difference decreased to 4.3% (CI, 2.9% to 5.5%; P < 0.001). The disparity in survival attributed to treatment differences made up only an absolute 0.6% of the overall 9.9% survival disparity.

Limitation: An observational study limited to elderly Medicare fee-for-service beneficiaries living in selected geographic areas.

Conclusion: Racial disparities in colon cancer survival did not decrease among patients diagnosed between 1991 and 2005. This persistent disparity seemed to be more related to presentation characteristics at diagnosis than to subsequent treatment differences.

Primary Funding Source: Agency for Healthcare Research and Quality and National Science Foundation.

Figures

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Figure 1.

Kaplan–Meier curve for colon cancer survival for black patients and 3 matched white populations diagnosed between 1991 and 2005.

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Figure 2.

Improvement in colon cancer survival for black and white patients from 1991 to 1998 versus 1999 to 2005.

The overall disparity did not change.

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