The Buzz This Week
A new analysis examining the feasibility of calculating measures of racial inequity in cancer data was released this week. Health Affairs assessed Medicare beneficiary chemotherapy-associated Emergency Department (ED) visits and hospitalizations and found that within the same practice, Black patients experienced an 8.1% higher rate of ED visits and 2.7% higher rate of hospitalization than white counterparts. Despite recognition that health inequities reduce overall quality of care, very few quality metrics incorporate measures of racial disparities. This study helps to highlight the need for reliable quality metrics measuring care disparities to tailor interventions to improve equity.
Successful attempts have been made to enact interventions in cancer where disparities were identified. The Accountability for Cancer Care through Undoing Racism and Equity (ACCURE) study made the following care delivery changes to improve disparities in breast and lung cancer care:
- Added automatic alerts for missed appointments to the electronic health record.
- Included a nurse navigator with training in race-specific barriers on the care team to follow up on alerts and aid patients in overcoming specific obstacles.
- Ensured a physician champion engaged with the care teams and provided feedback on treatment completion.
- Incorporated health equity education for the full care team.
Initial results published in 2018 showed treatment completion rates for Black patients went up from 79.8% to 88.4% and increased for white patients from 87.3% to 89.5%. Both groups saw increases in treatment completion, while the racial gap was nearly eliminated. Additional data published at the end of last year showed similar reductions in disparities for survival rates. For breast cancer, Black patients’ 5-year survival rate increased from 89% to 94%, while white patients saw an increase from 91% to the equivalent 94%. For early-stage lung cancer, Black patients’ survival rates increased from 37% to 54%, and white patients increased from 43% to 56%.
Why It Matters
According to Kaiser Family Foundation’s 2022 report on Racial Disparities in Cancer Outcomes, Black people continue to face the highest cancer mortality rate in the U.S., despite the largest decrease in mortality rate of any racial or ethnic group. Black populations also receive a lower overall rate of screening, are more likely to be diagnosed later, and are less likely to receive supportive care (including education, care navigation, pain management, and support groups).
Disparities in care also arise from homogenous screening guidelines that do not address different screening needs in various racial groups. Black women under age 45 have higher incidence rates of breast cancer, yet the U.S. Preventive Services Task Force (USPSTF) recommends mammogram screenings start at age 50. Similar disparities are seen in cervical cancer. Screening guidelines were recently changed to recommend a pap smear and hrHPV test every 3 to 5 years. Black women have the highest cervical cancer mortality rate of any racial or ethnic group, and limiting screening universally may delay vital treatment and worsen outcomes in this population. Additionally, modified guidelines may affect reimbursement. If insurers are not paying for screening, it could further decrease screening rates in vulnerable populations. Transparent quality metrics and data by race and ethnic group would help to create varied screening guidelines, ensuring reimbursement for necessary testing that can identify cancer earlier—leading to better outcomes overall.
The ACCURE team was successful because they understood what barriers were causing their patient population to miss vital care and screening, identified how those obstacles differed by race, and addressed the inequities through institutional change. Addressing racial disparities in cancer will require measurement of data and quality outcomes by race, appropriate screening guidelines for varying populations, access to education on screening, intentional change to care delivery at the institutional level that comprises a diverse and educated care team, appropriate staffing resources, and deliberate intervention when checkpoints are missed.
We Must Improve Equity in Cancer Screening