Annals of Surgical Oncology

, 16:2968 | Cite as

Racial Differences in Cancer Specialist Consultation, Treatment, and Outcomes for Locoregional Pancreatic Adenocarcinoma

  • Melissa M. Murphy
  • Jessica P. Simons
  • Sing Chau Ng
  • Theodore P. McDade
  • Jillian K. Smith
  • Shimul A. Shah
  • Zheng Zhou
  • Craig C. Earle
  • Jennifer F. Tseng
Healthcare Policy and Outcomes



Blacks have a higher incidence of pancreatic adenocarcinoma and worse outcomes compared to whites. Identifying barriers in pancreatic cancer care may explain survival differences and provide areas for intervention.


Pancreatic adenocarcinoma patients were identified in the Surveillance, Epidemiology, and End Results Registry (1991–2002). Treatment and outcome data were obtained from the linked Surveillance, Epidemiology, and End Results Registry–Medicare databases. Logistic regression was used to assess race as a predictor of specialist consultation/receipt of therapy. Kaplan–Meier survival curves were compared. Cox proportional hazard analyses were performed to estimate survival after adjustment for patient and treatment characteristics.


A total of 13,230 white patients (90%) and 1478 black patients (10%) were identified. Clinical/pathologic factors were compared by race. When we compared whites and blacks by univariate analyses, blacks had lower rates of specialist consultation (P < .01), chemotherapy (P < .01), and resection (P < .01). On multivariate analyses predicting consultation with a cancer specialist, black race negatively predicted consultation with a medical oncologist (adjusted odds ratio [AOR] .74, P < .01), radiation oncologist (AOR .75, P < .01), and surgeon (AOR .71, P < .01). For predicting receipt of therapy after consultation, blacks were less likely to undergo chemotherapy (AOR .59, P < .01) and resection (AOR .79, P = .05). Blacks had worse overall survival on Kaplan–Meier survival curves (log rank, P < .0001). On Cox proportional hazard modeling evaluating survival, black race was no longer independently associated with worse survival after adjustment for resection and adjuvant therapy (hazard ratio, 1.08; 95% confidence interval, .99–1.19).


Racial disparities exist in pancreatic cancer specialist consultation and subsequent therapy use. Because receipt of care is fundamental to reducing outcome discrepancies, these barriers serve as discrete intervention points to ensure all locoregional pancreatic adenocarcinoma patients receive appropriate specialist referral and subsequent therapy.


  1. 1.
    Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2008. CA Cancer J Clin. 2008;58:71–96.CrossRefPubMedGoogle Scholar
  2. 2.
    National Cancer Institute. SEER cancer statistics review 2005: age-adjusted SEER incidence and US death rates and 5-year relative survival rates. Accessed 4 Aug 2009.
  3. 3.
    Horner M, Ries LAG, Krapcho M, et al. SEER cancer statistics review, 1975–2006. Bethesda, MD: National Cancer Institute; 2009. Accessed 4 Aug 2009.
  4. 4.
    Fesinmeyer MD, Austin MA, Li CI, De Roos AJ, Bowen DJ. Differences in survival by histologic type of pancreatic cancer. Cancer Epidemiol Biomarkers Prev. 2005;14:1766–73.CrossRefPubMedGoogle Scholar
  5. 5.
    Warshaw AL, Fernandez-del Castillo C. Pancreatic carcinoma. N Engl J Med. 1992;326:455–65.PubMedGoogle Scholar
  6. 6.
    Bertagnolli MM. Surgical prevention of cancer. J Clin Oncol. 2005;23:324–32.CrossRefPubMedGoogle Scholar
  7. 7.
    Kalser MH, Ellenberg SS. Pancreatic cancer. Adjuvant combined radiation and chemotherapy following curative resection. Arch Surg. 1985;120:899–903.PubMedGoogle Scholar
  8. 8.
    Neoptolemos JP, Dunn JA, Stocken DD, et al. Adjuvant chemoradiotherapy and chemotherapy in resectable pancreatic cancer: a randomised controlled trial. Lancet. 2001;358(9293):1576–85.CrossRefPubMedGoogle Scholar
  9. 9.
    Chua YJ, Cunningham D. Adjuvant treatment for resectable pancreatic cancer. J Clin Oncol. 2005;23:4532–7.CrossRefPubMedGoogle Scholar
  10. 10.
    Oettle H, Post S, Neuhaus P, et al. Adjuvant chemotherapy with gemcitabine vs observation in patients undergoing curative-intent resection of pancreatic cancer: a randomized controlled trial. JAMA. 2007;297:267–77.CrossRefPubMedGoogle Scholar
  11. 11.
    Shavers VL, Brown ML. Racial and ethnic disparities in the receipt of cancer treatment. J Natl Cancer Inst. 2002;94:334–57.PubMedGoogle Scholar
  12. 12.
    Ayanian JZ, Zaslavsky AM, Fuchs CS, et al. Use of adjuvant chemotherapy and radiation therapy for colorectal cancer in a population-based cohort. J Clin Oncol. 2003;21:1293–300.CrossRefPubMedGoogle Scholar
  13. 13.
    O’Malley CD, Le GM, Glaser SL, Shema SJ, West DW. Socioeconomic status and breast carcinoma survival in four racial/ethnic groups: a population-based study. Cancer. 2003;97:1303–11.CrossRefPubMedGoogle Scholar
  14. 14.
    Steyerberg EW, Neville B, Weeks JC, Earle CC. Referral patterns, treatment choices, and outcomes in locoregional esophageal cancer: a population-based analysis of elderly patients. J Clin Oncol. 2007;25:2389–96.CrossRefPubMedGoogle Scholar
  15. 15.
    Steyerberg EW, Earle CC, Neville BA, Weeks JC. Racial differences in surgical evaluation, treatment, and outcome of locoregional esophageal cancer: a population-based analysis of elderly patients. J Clin Oncol. 2005;23:510–7.CrossRefPubMedGoogle Scholar
  16. 16.
    McCann J, Artinian V, Duhaime L, et al. Evaluation of the causes for racial disparity in surgical treatment of early stage lung cancer. Chest. 2005;128:3440–6.CrossRefPubMedGoogle Scholar
  17. 17.
    Bach PB, Cramer LD, Warren JL, Begg CB. Racial differences in the treatment of early-stage lung cancer. N Engl J Med. 1999;341:1198–205.CrossRefPubMedGoogle Scholar
  18. 18.
    Rogers SO, Ray WA, Smalley WE. A population-based study of survival among elderly persons diagnosed with colorectal cancer: does race matter if all are insured? (United States). Cancer Causes Control. 2004;15:193–9.CrossRefPubMedGoogle Scholar
  19. 19.
    Murphy MM, Simons JP, Hill J, Tseng JF. Pancreatic resection: a key component to reducing racial disparities in pancreatic adenocarcinoma. Cancer (2009). [Epub ahead of print].Google Scholar
  20. 20.
    Earle CC, Neumann PJ, Gelber RD, Weinstein MC, Weeks JC. Impact of referral patterns on the use of chemotherapy for lung cancer. J Clin Oncol 2002;20:1786–92.CrossRefPubMedGoogle Scholar
  21. 21.
    Tseng JF, Kronowitz SJ, Sun CC, et al. The effect of ethnicity on immediate reconstruction rates after mastectomy for breast cancer. Cancer 2004;101:1514–23.CrossRefPubMedGoogle Scholar
  22. 22.
    Warren JL, Klabunde CN, Schrag D, Bach PB, Riley GF. Overview of the SEER-Medicare data: content, research applications, and generalizability to the United States elderly population. Med Care. 2002;40 Suppl 8:IV-3–18.Google Scholar
  23. 23.
    Potosky AL, Riley GF, Lubitz JD, Mentnech RM, Kessler LG. Potential for cancer related health services research using a linked Medicare-tumor registry database. Med Care. 1993;31:732–48.CrossRefPubMedGoogle Scholar
  24. 24.
    World Health Organization. International classification of diseases for oncology. 3rd ed. Geneva: World Health Organization; 2000.Google Scholar
  25. 25.
    Bilimoria KY, Bentrem DJ, Ko CY, et al. National failure to operate on early stage pancreatic cancer. Ann Surg 2007;246:173–80.CrossRefPubMedGoogle Scholar
  26. 26.
    Zell JA, Rhee JM, Ziogas A, Lipkin SM, Anton-Culver H. Race, socioeconomic status, treatment, and survival time among pancreatic cancer cases in California. Cancer Epidemiol Biomarkers Prev. 2007;16:546–52.CrossRefPubMedGoogle Scholar
  27. 27.
    Bach PB, Guadagnoli E, Schrag D, Schussler N, Warren JL. Patient demographic and socioeconomic characteristics in the SEER-Medicare database applications and limitations. Med Care. 2002;40 Suppl 8:IV-19–25.Google Scholar
  28. 28.
    Klabunde CN, Warren JL, Legler JM. Assessing comorbidity using claims data: an overview. Med Care. 2002;40 Suppl 8:IV-26–35.Google Scholar
  29. 29.
    Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–83.CrossRefPubMedGoogle Scholar
  30. 30.
    Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol. 1992;45:613–9.CrossRefPubMedGoogle Scholar
  31. 31.
    Virnig BA, Warren JL, Cooper GS, et al. Studying radiation therapy using SEER-Medicare-linked data. Med Care. 2002;40 Suppl 8:IV-49–54.Google Scholar
  32. 32.
    International classification of diseases. 9th rev., clinical modification. Salt Lake City: Medicode Publications; 2001.Google Scholar
  33. 33.
    Kaplan EL, Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assn. 1958;185:1457–81.Google Scholar
  34. 34.
    Eloubeidi MA, Desmond RA, Wilcox CM, et al. Prognostic factors for survival in pancreatic cancer: a population-based study. Am J Surg. 2006;192:322–9.CrossRefPubMedGoogle Scholar
  35. 35.
    Krzyzanowska MK, Weeks JC, Earle CC. Treatment of locally advanced pancreatic cancer in the real world: population-based practices and effectiveness. J Clin Oncol. 2003;21:3409–14.CrossRefPubMedGoogle Scholar
  36. 36.
    Davila JA, Chiao EY, Hasche JC, et al. Utilization and determinants of adjuvant therapy among older patients who receive curative surgery for pancreatic cancer. Pancreas 2009;38:e18–25.CrossRefPubMedGoogle Scholar
  37. 37.
    Sewitch MJ, Fournier C, Dawes M, et al. Do physician recommendations for colorectal cancer screening differ by patient age? Can J Gastroenterol. 2007;21:435–8.PubMedGoogle Scholar
  38. 38.
    Samet J, Hunt WC, Key C, Humble CG, Goodwin JS. Choice of cancer therapy varies with age of patient. JAMA. 1986;255:3385–90.CrossRefPubMedGoogle Scholar
  39. 39.
    Rathore SS, Krumholz HM. Differences, disparities, and biases: clarifying racial variations in health care use. Ann Intern Med. 2004;141:635–8.PubMedGoogle Scholar
  40. 40.
    Dein S. Explanatory models of and attitudes towards cancer in different cultures. Lancet Oncol. 2004;5:119–24.Google Scholar
  41. 41.
    Whittle J, Conigliaro J, Good CB, Joswiak M. Do patient preferences contribute to racial differences in cardiovascular procedure use? J Gen Intern Med. 1997;12:267–73.CrossRefPubMedGoogle Scholar
  42. 42.
    Oddone EZ, Horner RD, Diers T, et al. Understanding racial variation in the use of carotid endarterectomy: the role of aversion to surgery. J Natl Med Assoc. 1998;90:25–33.PubMedGoogle Scholar
  43. 43.
    Lannon C, Brack V, Stuart J, et al. What mothers say about why poor children fall behind on immunizations. A summary of focus groups in North Carolina. Arch Pediatr Adolesc Med. 1995;149:1070–5.PubMedGoogle Scholar
  44. 44.
    Bach PB, Pham HH, Schrag D, Tate RC, Hargraves JL. Primary care physicians who treat blacks and whites. N Engl J Med. 2004;351:575–84.CrossRefPubMedGoogle Scholar
  45. 45.
    Ayanian JZ, Kohler BA, Abe T, Epstein AM. The relation between health insurance coverage and clinical outcomes among women with breast cancer. N Engl J Med. 1993;329:326–31.CrossRefPubMedGoogle Scholar
  46. 46.
    Perez-Stable EJ, Sabogal F, Otero-Sabogal R, Hiatt RA, McPhee SJ. Misconceptions about cancer among Latinos and Anglos. JAMA. 1992;268:3219–23.CrossRefPubMedGoogle Scholar
  47. 47.
    Fox SA, Stein JA. The effect of physician-patient communication on mammography utilization by different ethnic groups. Med Care. 1991;29:1065–82.CrossRefPubMedGoogle Scholar
  48. 48.
    Womeodu RJ, Bailey JE. Barriers to cancer screening. Med Clin North Am. 1996;80:115–33.CrossRefPubMedGoogle Scholar
  49. 49.
    Ayanian JZ, Cleary PD, Keogh JH, et al. Physicians’ beliefs about racial differences in referral for renal transplantation. Am J Kidney Dis. 2004;43:350–7.CrossRefPubMedGoogle Scholar
  50. 50.
    Ibrahim SA, Whittle J, Bean-Mayberry B, et al. Racial/ethnic variations in physician recommendations for cardiac revascularization. Am J Public Health. 2003;93:1689–93.CrossRefPubMedGoogle Scholar

Copyright information

© Society of Surgical Oncology 2009

Authors and Affiliations

  • Melissa M. Murphy
    • 1
  • Jessica P. Simons
    • 1
  • Sing Chau Ng
    • 1
  • Theodore P. McDade
    • 1
  • Jillian K. Smith
    • 1
  • Shimul A. Shah
    • 1
  • Zheng Zhou
    • 1
  • Craig C. Earle
    • 2
  • Jennifer F. Tseng
    • 1
  1. 1.Department of Surgery, Surgical Outcomes Analysis and ResearchUniversity of Massachusetts Medical SchoolWorcesterUSA
  2. 2.Institute for Clinical Evaluative Sciences, Sunnybrook Health Sciences CentreTorontoCanada

Personalised recommendations