© 1995 by Oxford University Press
Journal of the National Cancer Institute, Vol. 87, No. 22, 1686-1693,
November 15, 1995
© 1995 Oxford University Press
Determinants of Black/White Differences in Colon Cancer Survival
Department of Epidemiology, Rollins School of Public Health of Emory University Atlanta, GA
Department of Pathology, Louisiana State University Medical Center New Orleans
Oregon State Cancer Registry Portland
Department of Biostatistics, University of Pittsburgh School of Public Health PA
Department of Pathology and Laboratory Medicine, University of Cincinnati Medical Center OH
Office of Research on Women's Health, Office of the Director, National Institutes of Health Bethesda, MD
Formerly of Charles R. Drew School of Medicine and Science (retired), Rancho Palos Verdes CA
Comprehensive Cancer Center, Wake Forest University Winston-Salem, NC
Information Management Services, Inc. Silver Spring, MD
Division of Cancer Prevention and Control, National Cancer Institute Bethesda
Robert M. Mayberry, M.P.H., Ph.D., Department of Epidemiology, Rollins School of Public Health of Emory University, 1518 Clifton Rd., N.E., Atlanta, GA 30322.
BACKGROUND: Blacks have lower survival rates for colon cancer than whites, possibly related to more advanced stages of disease at diagnosis and to socioeconomic differences between blacks and whites. While the black/white difference in colon cancer survival is well documented, the few studies that have investigated this difference have been limited by the modest number and type of explanatory factors that were considered.
PURPOSE: We analyzed data from the National Cancer Institute Black/White Cancer Survival Study to determine 1) what characteristics might contribute to the racial difference in colon cancer survival and 2) if a survival disparity remained between black and white patients after adjustment was made for these characteristics.
METHODS: This prospective study included 454 blacks and a stratified random sample of 521 whites, aged 20–79 years, with cancer of the colon diagnosed from January 1, 1985, through December 31, 1986, and who were residents of the metropolitan areas of Atlanta, New Orleans, and San Francisco/Oakland. Follow-up was truncated on December 31, 1990. Cox proportional hazards regression was used to estimate the death rate among blacks relative to that among whites after adjustment for potential explanatory factors, including sociodemographic factors, concurrent (comorbid) medical conditions, stage at diagnosis, tumor characteristics, and treatment. All P values were calculated from two-tailed tests of statistical significance.
RESULTS: After adjustment for age, sex, and geographic area, the black-to-white mortality hazard ratio (HR) was 1.5 (95% confidence interval [CI] = 1.2–1.9), indicating that the risk of death among black patients was 50% higher than that among white patients. Further adjustment for stage reduced the excess cancer mortality to 20% (HR = 1.2; 95% CI = 1.0–1.5), decreasing the overall racial difference in excess mortality from 50% to 20% or to a 60% reduction in excess mortality. Although adjustment for poverty reduced the excess mortality by 20%, adjusting for both stage and poverty did not further reduce the racial difference. Among patients with stages II and III disease, blacks had lower survival rates than whites (HR = 1.8; 95% CI = 1.0–3.1 and HR = 1.5; 95% CI = 1.0–2.3, respectively). Among those patients with metastatic disease (stage IV), survival was similar for whites and blacks.
CONCLUSIONS: Stage at diagnosis accounted for more than half of the excess colon cancer mortality observed among blacks. Poverty and other socioeconomic conditions, general health status, tumor characteristics, and general patterns of treatment did not further explain the remaining survival disadvantage among blacks.
IMPLICATIONS: Because the racial disparity was confined to earlier stages, future studies should investigate whether blacks have more advanced disease at diagnosis and whether less aggressive treatment is provided because of understaging. [J Natl Cancer Inst 1995;87:1686–93]
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