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Cancer Medicine Science

Cancer disparities: Money matters

Cancer is an incredibly complicated disease. It’s not just differences in genetics and biology that determine outcomes, either. Cancer disparities is the study of factors that result in differences in outcome. Not surprisingly, money matters.

As I’ve written more times than I can remember, cancer is complicated. Really complicated. You just won’t believe how vastly, hugely, mind-bogglingly complicated it is. I mean, you may think balancing your checkbook is complicated, but that’s just peanuts to cancer. (Apologies to Douglas Adams.) First of all, contrary to the way alternative medicine mavens (and all too many people in general) portray it, cancer isn’t just one disease; it’s hundreds. Even cancer arising from the same organ might not be one disease. For instance, one study of a particularly aggressive subtype of breast cancer found that no two cancer genomes were the same, and, thanks to the power of evolution, the genetically unstable cancer cells lead to increasingly heterogeneous tumors as they grow, such that one part of a cancer might be significantly different from another part and metastases can be even more different. Phylogenetic trees can even be constructed. Cancer often involves many more cell types than just the cancer cell as well, not to mention the contribution of the immune system and metabolism in addition to the various genetic derangements in the cancer cells themselves. One area of cancer research where this complexity becomes apparent is cancer disparities.

I’ve discussed how lifestyle and diet can increase or reduce one’s risk, but there’s a whole other layer to the question of environmental effects on cancer risk and mortality. For instance, where you live matters. Your race or ethnicity can matter. Your socioeconomic status can matter. As the National Cancer Institute notes:

Cancer disparities (sometimes called cancer health disparities) are differences in cancer measures such as:

  • incidence (new cases)
  • prevalence (all existing cases)
  • mortality (deaths)
  • morbidity (cancer-related health complications)
  • survivorship, including quality of life after cancer treatment
  • burden of cancer or related health conditions
  • screening rates
  • stage at diagnosis

Cancer disparities can also be seen when outcomes are improving overall but the improvements are delayed in some groups relative to other groups.

Although disparities are often considered in the context of race/ethnicity, other population groups may experience cancer disparities. These include groups defined by disability, gender/sexual identity, geographic location, income, education, and other characteristics.

And here’s a video primer:

The one disparity that interests me as a breast cancer surgeon is the increased prevalence of triple negative breast cancer, a particularly nasty subtype, in premenopausal African American women, because our cancer center is in an area where half of our patients are African-American.

Basically, cancer disparities are where the rubber hits the road in a practical manner, as genetics, environment, lifestyle, and access to care can all impact who dies from cancer and who survives. So, for a change of pace (and because it interested me), I thought I’d look at a study of cancer disparities just published in JAMA Network Open on Friday that attempts to quantify cancer disparities. Its investigators include researchers from Yale and the University of Chicago, who report rather striking disparities in cancer death rates by county in in the US related to socioeconomic status.

The authors note:

Advances in cancer prevention, diagnosis, and treatment have led to rapid reductions in cancer mortality in the United States, with cancer death rates decreasing from 240 per 100,000 person-years in 1980 to 192 per 100 000 person-years in 2014.1-3 Reductions in cancer mortality, however, are not synonymous with reductions in cancer disparities—perhaps in part because of variation in access to advances in care. Indeed, cancer disparities remain substantial in the United States by geographic area and by socioeconomic status.4-6 The socioeconomic cancer disparities are notable in particular because they may worsen over time owing to the soaring costs of cancer diagnosis and treatment. Thus, there are major concerns about US socioeconomic disparities in cancer deaths.

To estimate cancer disparities, the investigators carried out a cross-sectional study assessing cancer disparities by county. They included all counties with cancer death rates available from 2014 in a database published by the Institute for Health Metrics and Evaluation. The database is based on data from the National Center for Health Statistics death record data and curated to eliminate “garbage codes, which are implausible or nonspecific causes of death.” The authors also linked the cancer death rate of each county to the median household income from 2012 in order to allow a two year lag prior to the primary outcome measure in 2014. The use of MHI is justified because it’s widely used and a readily available marker of socioeconomic status and because the authors expected it to have the most relevance to cancer death rates because of the financial toxicity of cancer.

So the primary outcome of this study was the age-adjusted cancer death rate per 100,000 person-years. Then:

To identify the factors that may serve as mediators of the association between the exposure and the outcome at the county level, we used time-lagged variables from the Robert Wood Johnson Foundation County Health Rankings conceptual model (eTable 1 in the Supplement). This model systematically evaluates and ranks counties according to a series of health risk factors that are selected on the basis of their validity and their importance in public health.17,18 It then groups these health factors into domains: health risk behaviors, clinical care factors, socioeconomic factors, and physical environment factors.18 We added a fifth domain to include cancer-relevant health policies—for example, the number of state-level mandates for insurance coverage of cancer care. Last, we added other factors, such as the presence of a comprehensive cancer center nearby, that were not included in the County Health Rankings model but were expected to be relevant to cancer outcomes.19,20 We obtained factors from multiple sources, including the Centers for Disease Control and Prevention, the American Lung Association, the National Cancer Institute, and the American Society of Clinical Oncology (eTable 1 in the Supplement).21-26

Counties were stratified into quartiles: low- (lowest quartile), medium- (middle quartiles), and high-income (highest quartile) groups. Regression models were used to identify multiple factors associated with the disparities found and to test the hypothesis that the various factors chosen above may serve as mediators of disparities between counties. The authors also used the sums of the values of the possible mediators to calculate a standardized risk score that they called the disparity risk index.

Not surprisingly, there were significant differences in cancer mortality found. A total of 3,135 counties were examined, with a median household incomes ranging from $22,126 to $121,250 per year. There were also striking differences in cancer death rates, which varied widely across counties, from 70.7 to 503.5 deaths per 100,000 person-years, the mean being 206.4. As one might predict, low income counties (median income $33,445) had a higher proportion of residents who were non-Hispanic black, lived in rural areas, or reported poor or fair health compared to high income counties (median income $55,780). The mean (SD) cancer death rate was 185.9 (24.4) per 100 000 person-years in high-income counties, compared with 204.9 (26.3) and 229.7 (32.9) per 100,000 person-years in medium- and low-income counties, respectively. There were also significant variations in cancer death rates by income group, with a mean death rate ± standard deviation of 229.7 ± 32.9 deaths per 100,000 person-years in the counties in the lowest quartile counties versus 204.9 ± 26.3 deaths per 100,000 person-years in the middle quartile counties and 185.9 ± 24.4 deaths per person-years in the highest quartile counties. The authors found that the geographic clusters, or hot spots, with the highest cancer death rates were in the South, including the Mississippi River Delta, in addition to Appalachia (n = 507 counties in hot spots at a threshold of P <  .05, Figure 2). There were many overlaps between these hot spots and low-income counties, as shown below in Figure 2 from the paper.

Cancer disparities

The authors tested various factors for whether they could be mediators of the observed disparities. A total of 38 factors were tested in a single-mediator model, which led 19 factors to meet the criteria for being included in a multi-mediator model. Of these, eight retained significance in the fully adjusted mediation model, suggesting that at least these eight county-level factors could be serving as mediators of the observed county-level socioeconomic cancer disparities. The authors note that these factors are important because they correlate with county-level MHI and because they could well fit into relevant pathways known to affect cancer risk and outcome. Of these, three factors were health risk behaviors (rates of obesity, smoking, and physical inactivity); two were health policies (smoke-free laws and the state Medicaid fee index, which is a state-level ratio of provider payments from Medicaid vs Medicare); and one was a health environment factor (food insecurity, defined as the percentage of the population that lacks a reliable source of food). The effects are shown on the graph below, specifically what percentage of the disparity observed is explained by each factor:

Cancer disparities
Factors associated with cancer disparities due to socioeconomic status.

As you can see by eyeballing the graph, much of the disparity can be explained by these factors, Indeed, the authors calculated that, in aggregate, these factors explained more than four-fifths (81.25%, to be precise) of the association between county-level median incomes and cancer death rates. As should be done, the statisticians did various sensitivity analyses, to see if the method choosing the variables affected the results. It didn’t. Different methods of variable selection led to similar models. So, basically, the final multivariable model “seemed to provide an accurate and robust estimate of the degree to which the factors may explain the disparities”, at least for this dataset and these variables.

Of course, this is an epidemiological study. Since it uses aggregated data and doesn’t look at individual-level date (e.g., MHI of individuals), it’s prone to the ecological fallacy (making inferences about the nature of individuals based on inference from the group to which they belong, most commonly deducing correlation between individual variables from the correlation of the variables collected for the group). Also, these are aggregated cancer death rates; they’re not broken out by cancer type. This means that large differences between the incidences of different cancers by county could confound results, although such confounding would provide interesting fodder for further research. In any event, this study is more hypothesis-generating for some correlations, although certainly finding that smoking, obesity, and physical inactivity are the strongest possible mediators of the cancer disparities is confirmatory of a lot of what we know already.

Two other major findings of this study included the finding that food insecurity and access to quality medical care are associated with higher cancer death rates. The authors note:

There are multiple ways in which these 2 factors may account for disparities in cancer deaths. For example, low-quality clinical care may lead to delays in the diagnosis and treatment of cancer, and food insecurity may increase the incidence of certain cancers in populations due to poor nutrition, even if obesity rates are similar. Efforts to target nonbehavioral mediators might be useful in light of evidence that addressing health risk behaviors is necessary but not sufficient if the ultimate goal is to eliminate health disparities.46,47 In addition, the issue of regular access to healthy foods, or food security, might warrant further consideration in future studies of cancer disparities. This is because studies suggest that food insecurity is correlated with poor health,48 high costs,49 and obesity—a key risk factor for cancer.10 In addition, because obesity is a risk factor for diabetes and cardiovascular disease, efforts to address it might lead to substantial gains in population-level health outcomes.

There’s also this:

Finally, to address disparities, it may be critical to maintain policies that are associated with better outcomes in low-income communities. For example, efforts to limit the expansion of Medicaid may undermine efforts to lessen socioeconomic cancer disparities, in part because the states with vs without Medicaid expansions have had larger improvements in screenings for and early detections of cancer.50,51 Our study adds to these findings by suggesting that limited access to affordable care is a mediator of cancer disparities, at the same time as many of the low-income counties with the highest mortality rates are in the states that eschewed the expansion.

I realize that people don’t like it when we get political here, even if it’s a little bit political, but the fact that the US, alone among developed nations, does not have a system of universal health insurance for its citizens virtually guarantees major disparities. At the very minimum, it means that existing disparities are not ameliorated. Disparities research is a reminder that it’s impossible to separate politics from medicine, because science-based public health care policies will inevitably mean making choices in law and regulation. Those choices are inherently political. Also, money and income matter. They matter a lot.

Ameliorating disparities in cancer outcome and incidence is also very difficult, because so many factors affect them. There are biological differences among populations, socioeconomic differences, differences in environmental exposures, differences in health behaviors, differences in so many things, that it’s hard to tell how much of which disparity is likely to be caused or mediated by what factor. Thus designing and implementing strategies to reduce these disparities are among the most difficult challenges cancer professionals face.

By Orac

Orac is the nom de blog of a humble surgeon/scientist who has an ego just big enough to delude himself that someone, somewhere might actually give a rodent's posterior about his copious verbal meanderings, but just barely small enough to admit to himself that few probably will. That surgeon is otherwise known as David Gorski.

That this particular surgeon has chosen his nom de blog based on a rather cranky and arrogant computer shaped like a clear box of blinking lights that he originally encountered when he became a fan of a 35 year old British SF television show whose special effects were renowned for their BBC/Doctor Who-style low budget look, but whose stories nonetheless resulted in some of the best, most innovative science fiction ever televised, should tell you nearly all that you need to know about Orac. (That, and the length of the preceding sentence.)

DISCLAIMER:: The various written meanderings here are the opinions of Orac and Orac alone, written on his own time. They should never be construed as representing the opinions of any other person or entity, especially Orac's cancer center, department of surgery, medical school, or university. Also note that Orac is nonpartisan; he is more than willing to criticize the statements of anyone, regardless of of political leanings, if that anyone advocates pseudoscience or quackery. Finally, medical commentary is not to be construed in any way as medical advice.

To contact Orac: [email protected]

14 replies on “Cancer disparities: Money matters”

Unfortunately, in the current climate, the odds of our political leaders doing anything meaningful to address these disparities is a pipe dream. They’ll just blame the patient for whatever (not working, not working hard enough, not eating right whatever they can come up with) and do nothing. Conspiracy theorists will just deny the evidence.

Heck, we can’t even get coherent policy on climate change.

It was chilling for me to see just how much red there was on that map where I live.

You are completely correct Panacea. Our current (useless) Republican in chief would prefer to blame the victims rather than solve real problems

Too many issues for detailed, short answers.

Cancer treatment costs are what one choses, or has chosen for them. Between countries, I saw retail 5FU-LV treatment costs varied from $60/mo to $20,000/mo, without any subsidy. Likewise, targets might be treated with 2 cents pills off label or $30,000+/mo std of care. High 5FU-LV costs are pure politics and corruption, with a lack of competition in cheap oral drugs.

In the complementary/alternative world, the multiplicity of pathways may be addressed by multiple, low toxicity nutrients and off label, generic drugs. One can argue that this is likely often necessary beyond several “standard” adjuncts because of their horrific toxicities on a cumulative basis simply destroy the human body. The newer drugs’ horrific cost also destroys ones finances. More recently, the monopoly effects of various US regulations and “protection” laws has decreased price competition so much we have incidents like Martin Shkreli, jacking a 5 cent generic pill up to $750. In the US, it can take a lot of work, skill and mental horsepower, to avoid being protected to death, including medically.

“Universal health insurance” is a political bait in the US for more financial predation by various groups in the medical, financial, and political industries. Why would anyone trust them with more political and financial powers to make a bigger mess with a bigger police state? Certainly not me – freedom of medical choice is more likely to be extinguished in such a prescriptive US system, despite whatever promises are made, again. The last US medical insurance grab threatened to cost almost $50,000 per year to collect the first 60-80 cents of co-payment. “No thanks”.

Finally, poor food choices are a combination of factors, from miseducation, sloppiness, ignorance, low IQ, government meddling, restricted choices, and finances. I’ve hired poor caretakers who spent more on junk food than I spent on myself. In the past, I’ve been victimized by common miseducation and propaganda; even today I can make sloppy choices on excess carbs.

Well…thank you for the libertarian take on health care and diet.

Personally, I benefit greatly from government run healthcare–Medicare. Too bad I had to wait til I was 65 to get it.

I don’t have to be a libertarian to identify issues or shop harder.

Medicare is probably better insurance than most younger people are getting now. I do doubt the ability of USG to deliver expanded/universal Medicare for an affordable price tag nationwide even with more restrictions and controls. One place I’ve lived, most doctors have already quit Medicare.

People who aren’t successful under US “std of care” are going to want better answers elsewhere. Mandatory financial participation at high costs usually destroys that choice. With one parent, nursing home care under Medicare became untenable because of apparent “std of care” regs (state too) that we abandoned the US, still paying Medicare.

My spouse has national health insurance. It’s cheap and we’re reasonably happy with it, but you and your US doctors wouldn’t want it. It does provide universal coverage for all conditions but at a gut wrenching minimum service level if the government pays the bill, far below Medicaid services for expensive conditions. Beyond that, it is more like a discount card with capped costs at tiered hospitals. We pay most of the actual medical bill, in cash, either way, or can get private insurance, with very low annual ceilings. In some cases, we would have to do without “std of care” for the US if we needed/wanted it. In the US, I would expect armed revolution over such policies. But we have had other treatment choices, that we’ve done better with than stateside, so far dealing with cancer issues.

I read this comment this morning and thought it really misses the point. This survey is looking at how much treatment success (or failure) varies simply by where you live and how much you earn, which is somewhat related. And there is some discussion about how we might correct those inequalities.

But you persist in hammering on your favorite themes of alternate cures and pharma/science conspiracies.

So I thought a poetic response would be appropriate, with apologies to Ernest Lawrence Thayer.

Ten thousand eyes were on him as he touted Vitamin C;
Five thousand tongues applauded when he praised the Vitamin D.
Then while the medical professionals talked of healing for the sick.,
Defiance flashed in PRN’s eye, a sneer curled PRN’s lip.

And now ideas of how to improve were tossed about the
air,
And PRN stood a-listening to it in haughty grandeur there.
Close by the sturdy batsman the cures unheeded sped—
“That ain’t my style,” said PRN. “Strike one!” the umpire said.

From the alt-blogs, filled with anecdotes, there went up a muffled
roar,
Like the wailing of a didgeridoo on a stern and distant shore;
“Kill him! Kill the umpire!” shouted someone with a tweet;
And it’s likely they’d have killed him had not PRN scraped his feet.

With a smile of Dunning confidence great PRN’s visage shone;
He stilled the rising tumult; he bade the game go on;
He signaled to the pitcher, and once more questions flew;
But PRN still ignored them and the umpire said, “Strike two!”

“Fraud!” cried the maddened thousands, and echo answered
“Fraud!”
But one scornful look from PRN and the audience was awed.
They saw his face grow stern and cold, they sensed his neural
strain,
And they knew that PRN wouldn’t let the discussion wane.

The sneer is gone from PRN’s lip, his teeth are clenched in hate,
He pounds with cruel violence his bat upon the plate;
And now the Orac talks of cancer, and healing for the poor,
And now the air is shattered by the force of PRN’s blow.

Oh, somewhere in this favoured land the sick are healing well,
The stricken down are walking now, their family’s hearts are light;
And men now cured are laughing, and healthy children
shout,
But there is no joy in Altville—mighty PRN has struck out.

I was watching the local news last week, and a segment came on about a local group doing fundraisers to help people dealing with cancer pay their home utility bills. They interviewed a woman who works 40 hours at a local school as an aide and then 25 hours on weekends at some other job, and she still cannot make ends meet. Right after the segment, and I mean immediately, a political commercial for Scott Perry (Republican from PA’s 10th District) came on. “Liberals” want “Socialism” in our healthcare, it warned. Then they put up a woman with a British accent telling us how badly the healthcare system in the UK treated her, and how people “died while waiting for care” there. Like they don’t here?
And that was it. No references to evidence. No fine print on how they came up with this determination. It was as if the woman called “The General” Perry and said, “Oy, mate. I’ll set ’em straight on socialised healthcare, I will.” And Scott was like, “Cool beans. Just record yourself with your iPhone or whatever.”

Yeah, that’s really frustrating. I have friends in Canada. They admit their system has its flaws but overall are very satisfied with it. I remember having to drive a friend to Edmonton so she could have her knee surgery. They picked the date and either she went or it was rescheduled . . . on their schedule. It was an elective procedure, though. She was hoping it would help her when she entered the police academy. What she really needed was a ride home since she would be able to drive her manual transmission car on her own post operatively.

People think our free market system doesn’t ration care. It does. Very much so. Private company bureaucrats take the place of the dreaded government bureaucrats, but the bottom line is a non-medical person in an office reading from an algorithm decides when and if you can have treatment based on what your plan pays for.

I’m fairly certain that knee surgeries have turned into something of a cash cow for hospitals. The reason they’re so hard to get in Canada is that there’s a good chance the patient can recover with surgery and you’re expected to try exercise and rehab else first. It bugs me to no end that everyone points to the waiting lists for knee surgeries to prove American health care is better than Canadian. Heart bypasses are similar. Quit smoking and eat better before you consider such an intense and dangerous operation.

Oh, no question in my mind on that.

My dad had a quadruple bypass at age 76, 12 years after a cardiac cath identified a 90% blockage in one coronary artery (not sure which one but probably not the widowmaker). At the time, his cardiologist told him watch and wait was the standard of care, and he did very well for years. He never did have an MI. He quit smoking, drinking, and lost the weight.

I live in a country with universal health care. Wouldn’t swap it with the US model. It isn’t perfect but, with bulk billing, GP and hospital attendances are “free” and a pharmacy benefits scheme means that most medications cost less that $7.00 per script to people who are on a pension. Last time I looked we weren’t a police state either and we’ve had universal health care since 1973. I’m not sure our system would work in the USA as all eligible taxpayers pay a 2% surcharge on their taxable income to fund the scheme. Now that, I think, would get your the wing pundits knickers in a knot. Out here meh.

I am reminded that Rush Limbaugh promised that if Obamacare passed he was going to live in Costa Rica. Many people pointed out they have universal health care. If Costa Rica can do it, but we can’t something is wrong somewhere.
I have seen close up the consequences of sick people lacking the insurance or money to access medical services. It was all too often tragic, and patients on Medicaid fared little better. When the makers of albuterol inhalers had to change propellant they also made other changes and patented them, wiping out the generics. I have had battles for patients and self with insurance companies that didn’t pay for obviously lifesaving care or used stupid rules to question treatments, and providers that tried to get payments they weren’t entitled to.
On the other hand, I remember a fight with a state Medicaid pharmacist to approve an expectorant that was not terpin hydrate. The patient had an esophageal ulcers.I wasn’t going to give him a drug that was about 40% alcohol, and useless, worthless crap besides (It was taken off the market a few years later.). He was so implacable that I called him a bureaucrat, bracketed with several words that were considerately less temperate.
So, if we ever do get a one-payor system, we had better work it out very carefully before it goes into effect, so we can avoid disasters like the initial rollout of Obama’s plan.

Costa Rica is a lovely, beautiful place with really great people. But sadly, I don’t think we’ll be able to do their trick with universal healthcare, because the reason they have that (and a whole lot of other nice things as well) is because they don’t have an army. And when would the US get rid of any of our military?

A perfect system will exist only after the Earth becomes a post-subsistience society (so, like, a million years, give or take), but we shouldn’t stop trying.

I had forgotten that fact about Costa Rica. It’s probably the case with Canada too – they maintain a fairly small military, one that in recent history was poorly equipped. On the other hand, countries with quite substantial militaries somehow manage to do both. That includes France, the UK, Israel, Sweden, and others. Switzerland, which maintains a high state of military preparedness, has a plan that appears to me to be the basis for Gingrich-/Romney-/Obamacare. They are as capitalist as nations come, don’t seem to like Muslims very much, and stay out of other countries’ business; their healthcare system should appeal to Republicans like cheese appeals to a dog. Maybe the fact that they are a functioning multilingual society undercuts the Mexican-rapists-under-the-bed-while-they-steal-our-jobs mishegoss that they peddle.
(Orac, please note new email address.)

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