In August, acclaimed actor Chadwick Boseman tragically passed away at age 43 after a four-year battle with colon cancer. Boseman played the role of Black Panther as well as several African American historical icons, some of which he filmed while quietly undergoing cancer treatment.
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Colorectal cancer, which is characterized by the uncontrolled growth of abnormal cells in the colon or rectum, accounts for 8.2% of all new cancer cases and is the second leading cause of cancer death in the United States. Colon cancer also disproportionately affects communities of color and economically marginalized populations.
As part of U.S. News’ ongoing series on health equity, U.S. News data analysts took a closer look at disparities in colon cancer and found stark differences in who was diagnosed, at what stage, and how they fared. Black, Hispanic and low socioeconomic status patients were less likely to be screened, more likely to be admitted for an emergent procedure, and had an increased risk of mortality and shorter overall survival time compared with wealthier, white patients. This analysis, combined with an investigation of peer-reviewed literature and interviews with clinical experts, revealed the pivotal role that preventive care has in driving some of these disparities.
Factors that contribute to cancer disparities across racial and socioeconomic lines are complex and interrelated. Socioeconomic status here refers to individuals who are simultaneously enrolled in both Medicare and Medicaid. In 2018 there were 12.2 million dual eligible beneficiaries, 60% of whom have multiple chronic conditions, according to the Centers for Medicare & Medicaid Services.
Many dual eligible patients also experience a higher burden of social risk factors, such as poverty and limited access to community resources, and need ongoing long-term care services and support. The racial breakdown of Medicare beneficiaries by dual eligibility status in Table 1 shows that both Black and Hispanic patients are overly represented in the dual eligible portion of the population, when compared with the breakdown of all eligible beneficiaries. For example, despite making up only 11% of all Medicare beneficiaries, Black patients are 20% of dual eligible beneficiaries. This trend is reversed for white patients, who comprise 80% of all Medicare beneficiaries but just 62% of dual eligible beneficiaries. These statistics indicate that Black and Hispanic Medicare beneficiaries are more likely to be dual eligible than their white counterparts.
Among Medicare patients with colon cancer who underwent surgery, Black and Hispanic patients experienced longer hospital stays, and they were more likely to be readmitted to the hospital within 30 days of the procedure compared with their white counterparts, after accounting for comorbidities. While Hispanic patients had an increased risk of mortality within 30 days of the procedure, there was a reduced risk of death among Black patients, when compared with white patients. Figure 1 demonstrates the risk of these outcomes by race and socioeconomic status. Within each race and ethnic category, we see that dual eligible patients in fact consistently experience a higher risk of poor outcomes after undergoing colon cancer surgery.
Looking at the crude rate of mortality for all patients with a colon cancer diagnosis, as opposed to just those who received surgery, revealed a different story. Black patients had a 6.7% increased risk of death while Hispanic patients had a 1.4% increased risk of death, compared with white patients. Black and Hispanic patients with colon cancer also experienced a shorter average survival time compared with their white counterparts.
From the time of their initial colon cancer diagnosis, our analysis of Medicare inpatient claims revealed that white patients lived on average 23.9 days longer than Black patients, and 40.8 days longer than Hispanic patients. We took a deeper dive into what could be driving these disparities, through the lens of preventive care.
We found that both Black and Hispanic Medicare patients were less likely to receive surgery after a diagnosis of colon cancer compared with their white peers. If this disparity was not present, 450 additional Black and Hispanic Medicare patients with colon cancer would have undergone surgery over the seven-year analysis period. This finding supports recent literature, which indicates that Black patients were less likely to receive any treatment after a diagnosis of colon cancer, including chemotherapy. And when minority Medicare patients did receive surgery, the procedure was more frequently considered to be emergent (Figure 2). This disparity is also notable for dual eligible patients.
Emergent procedures are often cases of acute bowel obstruction, which if left untreated can lead to severe abdominal pain and even perforation of the bowel, according to Dr. Otis Brawley, oncologist and epidemiologist at the Johns Hopkins Kimmel Cancer Center and Bloomberg School of Public Health in Baltimore. These patients sometimes go “directly from the emergency room to the OR in the middle of the night,” he says. These procedures can also become significantly more complex than elective or nonemergent procedures because “you’re dealing with an infection problem and a cancer problem at the same time,” he adds. When colon cancer is identified earlier, people are less likely to arrive at the hospital for such an acute episode, and complications from emergent admissions can be mitigated.
Screening serves as a vital tool for prevention and early detection of colon cancer, by reducing the incidence of disease and also increasing the likelihood of survival for those who are diagnosed. But clear racial and socioeconomic disparities exist in who gets the recommended screening for colorectal cancer, according to an analysis of data from the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System. The BRFSS is a national survey that gathers information at the state level on various health-related behaviors, chronic health conditions and use of preventive services.
In 2018, the prevalence of people aged 50 to 75 who reported having a colonoscopy in the past 10 years was almost 40% higher among those with a household income of $50,000 or more than those who earned less than $15,000. Map 1 shows that this pattern of increasing screening rates with higher income levels persists in a majority of states across the country. According to another CDC dataset, the National Health Interview Survey, colorectal screening was the lowest among the uninsured (25%) and immigrants who resided in the U.S. for less than 10 years (35%).
A contributing factor to alleviating screening disparities in recent years is the Affordable Care Act, which has reduced the number of uninsured individuals and lowered or eliminated the out-of-pocket screening costs for the uninsured. However, the Supreme Court’s ruling in 2012 allows states to opt out of the ACA’s Medicaid expansion, which 12 states have decided to do as of today. Nearly 4 million more Americans would qualify for health insurance if all states chose to enact Medicaid expansion under the ACA, a 2013 study found.
We compared these state-level screening rates with data from CMS on which states adopted Medicaid expansion as of January 2018 (Table 2). We found that states that adopted Medicaid expansion had higher screening rates across almost all income levels. Furthermore, the disparity between the highest and lowest income categories was 18% greater in states that did not expand. A similar pattern was observed along racial and ethnic lines. States that expanded Medicaid achieved higher screening rates across all groups and also smaller gaps between their citizens of color and white residents (Table 3). This result suggests that government policy decisions can have dramatic effects not only on health care but also health equity.
The lack of early intervention for colon cancer that stems from economic and racial screening disparities has downstream implications far beyond delayed diagnosis. A recently published study found that screening was significantly associated with both reduced colorectal cancer risk and reduced mortality. Particularly, use of a colonoscopy was found to be associated with a 35% reduced incidence of colorectal cancer among Black study participants, and a 37% reduced incidence for participants with an annual household income of less than $15,000. Other research demonstrates that tumor presentation, including the stage at the time of diagnosis, is “one of the most important factors in contributing to the racial disparity in colon cancer survival.” Researchers with the Division of Cancer Prevention and Control found that Black patients with colon cancer presented with a later stage of disease at diagnosis than white patients. Similar findings were discovered in our analysis of Medicare data: Black and Hispanic patients were more likely to have metastatic cancer that has spread to regional or distant sites, at the time of initial diagnosis.
Although screening is a major key in finding the solution to colon cancer disparities, Dr. Brawley points out that prevention is also paramount, but often overlooked or de-emphasized. “The problem with American health care is that we don’t try to prevent these diseases nearly enough,” he says. Balanced diets that are high in fruits, vegetables and whole grains have been “proven to lower one’s risk of colon cancer and colon cancer polyps,” he adds. While this can be driven by personal decision-making, poor diet and obesity can’t be isolated from the socioeconomic inequalities that exist in our society.
Access to food that is healthy, affordable and nutritious is a challenge for many Americans, particularly those living in low-income neighborhoods, communities of color and rural areas. These problems are cyclical – the same issues that increase one’s risk of developing disease also become the ones that create barriers to getting the necessary care for that illness. Resolving the inequities in colon cancer outcomes will require an approach as complex and multifactorial as the issues that created them. Policies at all levels of government have the power to address these by improving access to health care coverage, resources and education for vulnerable communities. Only by acknowledging that these disparities exist and working toward understanding why they prevail can America move toward a more equitable health care system.
With contributions by Meera Suresh, Ben Harder and Zach Adams.