Disparities in Socioeconomic Factors Mediate the Impact of Racial Segregation Among Patients With Hepatopancreaticobiliary Cancer

• Published in: Annals of surgical oncology 2023-08, Vol.30 (8), p.4826-4835
• Main Authors: Munir, Muhammad Musaab, Woldesenbet, Selamawit, Endo, Yutaka, Moazzam, Zorays, Lima, Henrique A, Azap, Lovette, Katayama, Erryk, Alaimo, Laura, Shaikh, Chanza, Dillhoff, Mary, Cloyd, Jordan, Ejaz, Aslam, Pawlik, Timothy M.
• Format: Article
• Language: English
• Subjects: Aged; Black or African American - statistics & numerical data; Cancer; Digestive System Neoplasms - diagnosis; Digestive System Neoplasms - ethnology; Digestive System Neoplasms - mortality; Digestive System Neoplasms - surgery; Epidemiology; Health Services Accessibility - statistics & numerical data; Health Status Disparities; Healthcare Disparities - ethnology; Healthcare Disparities - statistics & numerical data; Hepatobiliary Tumors; Humans; Medicare; Medicine; Medicine & Public Health; Mobility; Mortality; Neoplasms - diagnosis; Neoplasms - ethnology; Neoplasms - mortality; Neoplasms - surgery; Oncology; Outcome Assessment, Health Care - statistics & numerical data; Patients; Principal components analysis; SEER Program - statistics & numerical data; Segregation; Social Determinants of Health - ethnology; Social Determinants of Health - statistics & numerical data; Social Segregation; Socioeconomic Factors; Surgery; Surgical Oncology; Systemic Racism - ethnology; Systemic Racism - statistics & numerical data; United States - epidemiology; White - statistics & numerical data
• ISSN: 1068-9265; 1534-4681
• DOI: 10.1245/s10434-023-13449-9

Background Structural racism within the U.S. health care system contributes to disparities in oncologic care. This study sought to examine the socioeconomic factors that underlie the impact of racial segregation on hepatopancreaticobiliary (HPB) cancer inequities. Methods Both Black and White patients who presented with HPB cancer were identified from the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database (2005–2015) and 2010 Census data. The Index of Dissimilarity (IoD), a validated measure of segregation, was examined relative to cancer stage at diagnosis, surgical resection, and overall mortality. Principal component analysis and structural equation modeling were used to determine the mediating effect of socioeconomic factors. Results Among 39,063 patients, 86.4 % ( n = 33,749) were White and 13.6 % ( n = 5314) were Black. Black patients were more likely to reside in segregated areas than White patients (IoD, 0.62 vs. 0.52; p < 0.05). Black patients in highly segregated areas were less likely to present with early-stage disease (relative risk [RR], 0.89; 95 % confidence interval [CI] 0.82–0.95) or undergo surgery for localized disease (RR, 0.81; 95% CI 0.70–0.91), and had greater mortality hazards (hazard ratio 1.12, 95% CI 1.06–1.17) than White patients in low segregation areas (all p < 0.05). Mediation analysis identified poverty, lack of insurance, education level, crowded living conditions, commute time, and supportive income as contributing to 25 % of the disparities in early-stage presentation. Average income, house price, and income mobility explained 17 % of the disparities in surgical resection. Notably, average income, house price, and income mobility mediated 59 % of the effect that racial segregation had on long-term survival. Conclusion Racial segregation, mediated through underlying socioeconomic factors, accounted for marked disparities in access to surgical care and outcomes for patients with HPB cancer.