Journal of the National Cancer Institute Advance Access published online on May 13, 2008
JNCI Journal of the National Cancer Institute, doi:10.1093/jnci/djn145
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Residual Treatment Disparities After Oncology Referral for Rectal Cancer
Affiliations of authors: Department of Surgery, University of Michigan, Ann Arbor, MI (AMM, AJH, JDB); Michigan Surgical Collaborative for Outcomes Research and Evaluation, University of Michigan, Ann Arbor, MI (AMM, JDB); Department of Family Medicine, University of Washington, Seattle, WA (BM, LMB); Department of Surgery, Oregon Health and Science University, Portland, OR (KGB)
Correspondence to: Arden M. Morris, MD, MPH, Department of Surgery, University of Michigan, 1500 East Medical Center Dr, TC-5343, Ann Arbor, MI 48109-0331 (e-mail: ammsurg{at}umich.edu).
Background: Black patients with rectal cancer are considerably less likely than white patients to receive adjuvant therapy. We examined the hypothesis that the lower treatment rate for blacks is due to underreferral to medical and radiation oncologists.
Methods: We used 1992–1999 Surveillance, Epidemiology, and End Results–Medicare data to identify elderly (
66 years of age) patients who had been hospitalized for resection of stage II or III rectal cancer (n = 2716). We used 
2 tests to examine associations between race and 1) consultation with an oncologist and 2) receipt of adjuvant therapy. We then used logistic regression to analyze the influence of sociodemographic and clinical characteristics (age at diagnosis, sex, marital status, median income and education in area of residence, comorbidity, and cancer stage) on black–white differences in the receipt of adjuvant therapy. All statistical tests were two-sided.
Results: There was no statistically significant difference between the 134 black patients and the 2582 white patients in the frequency of consultation with a medical oncologist (73.1% for blacks vs 74.9% for whites, difference = 1.8%, 95% confidence interval [CI] = >5.9% to 9.5%, P = .64) or radiation oncologist (56.7% vs 64.8%, difference = 8.1%, 95% CI = >0.5% to 16.7%, P = .06), but blacks were less likely than whites to consult with both a medical oncologist and a radiation oncologist (49.2% vs 58.8%, difference = 9.6%, 95% CI = 0.9% to 18.2%, P = .03). Among patients who saw an oncologist, black patients were less likely than white patients to receive chemotherapy (54.1% vs 70.2%, difference = 16.1%, 95% CI = 6.0% to 26.2%, P = .006), radiation therapy (73.7% vs 83.4%, difference = 9.7%, 95% CI = 0.4% to 19.8%, P = .06), or both (60.6% vs 76.9%, difference = 16.3%, 95% CI = 4.3% to 28.3%, P = .008). Patient and provider characteristics had minimal influence on the racial disparity in the use of adjuvant therapy.
Conclusion: Racial differences in oncologist consultation rates do not explain disparities in the use of adjuvant treatment for rectal cancer. A better understanding of patient preferences, patient–provider interactions, and potential influences on provider decision making is necessary to develop strategies to increase the use of adjuvant treatment for rectal cancer among black patients.
| CONTEXT AND CAVEATS Prior knowledge Black patients with rectal cancer are considerably less likely than white patients to receive adjuvant therapy, but it is unclear whether this disparity is due to underreferral of blacks to medical and radiation oncologists. Study design
Surveillance, Epidemiology, and End Results (SEER)–Medicare data were used to identify elderly ( Contribution There was no difference in the frequency of consultation with a medical or radiation oncologist between the black patients and the white patients, but blacks were less likely than whites to consult with both a medical oncologist and a radiation oncologist. Among patients who saw an oncologist, black patients were less likely than white patients to receive chemotherapy, radiation therapy, or both. Patient and provider characteristics had minimal influence on the racial disparity in the use of adjuvant therapy. Implications A better understanding of patient preferences, patient–provider interactions, and potential influences on provider decision making is necessary to develop strategies to increase the use of adjuvant treatment for rectal cancer among black patients. Limitations Aggregate data were used to describe patient-level income. Patient and physician decision making was not explored. Medicare data are limited to patients older than 65 years; thus, the findings may not apply to all patients with rectal cancer.
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Manuscript received November 28, 2007; revised March 20, 2008; accepted April 7, 2008.
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J Natl Cancer Inst 2008 100: 687.
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