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#WhiteCoatsForBlackLives is trending. What does it mean for oncology? One thing is certain: we have a long way to go in achieving equitable cancer outcomes across diverse populations. Reasons span from biological differences unaccounted for in demographically-skewed trial-informed standards of care to systemic inequities in access to basic healthcare. Today’s special edition QuadShot highlights data demonstrating race-based disparities reported in the 3 years since our inception—just a snippet of what’s out there—in hopes we can all reflect on just how much we have left to learn.
We’ve learned that the commonly held belief that prostate cancer in black men has “bad biology” may not be so accurate. That notion came from poor prostate cancer survival outcomes for black men. Black men indeed have “different” prostate cancer biology, but in a genomic meta-analysis of RTOG trials, they had better prostate cancer outcomes than their white counterparts. In another trial, black men had a longer time to PSA progression on abiraterone than white men. A meta-analysis of several docetaxel trials for metastatic prostate cancer found that black men had a lower risk of death compared to whites. An even bigger analysis of SEER, VA, and RTOG data showed that the poor real-world outcomes for black men were strongly associated with poor socioeconomic factors. When these factors were accounted for, black men had similar, if not better, prostate cancer survival.
Data for many screening programs relies on identifying high risk behaviors and populations. Unfortunately, large lung and prostate cancer screening studies were very minority minorities. When it comes to smoking, there are major social differences in “high risk” smoking behavior between blacks and whites. As a result, a recent study found that current lung cancer screening criteria under-represents high-risk smoking patterns among black smokers leading to higher rates of incident lung cancer in screening ineligible patients.
Recent shifts in cancer epidemiology include important racial differences that we don't completely understand. For instance, hysterectomy-corrected rates of endometrial cancer are rising in the U.S. as a result of significant increases in rates of more aggressive, non-endometrioid histologies primarily among non-white women. On the other hand, mortality rates for colorectal cancer are rising among young white patients in the US. Likewise, the proportion of young white and hispanic women diagnosed with lung cancer is rising relative to men.
Finally, in states that expanded insurance access under the ACA, there was a significant increase in the proportion of patients (particularly minorities) receiving timely cancer care. But while increased access reduced cancer mortality for some minority groups, black patients didn’t have the same proportional decrease with ACA expansion. In other words, we've got a lot to left to learn about racial determinants of disease, treatment outcomes, and access to care.