Skip to main content

Advertisement

SpringerLink
Log in

Racial Disparities in Surgery for Malignant Bowel Obstruction

  • Gastrointestinal Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Operative management of patients with malignant bowel obstruction (MBO) may provide effective palliation, but is associated with substantial risks. This study aimed to analyze racial and ethnic differences in surgical outcomes for patients with MBO.

Methods

This retrospective study, using National Surgical Quality Improvement Program (NSQIP) registry data from 2010 to 2019, compared differences in outcomes by race and ethnicity for 2762 patients undergoing surgery for MBO. Multivariable logistic regression controlled for relevant covariates.

Results

Black patients (n = 407) had higher rates of preoperative comorbidity and were more likely than White patients (n = 2081) to have major complications (28.5% vs 21.8%; p = 0.0031), overall complications (47.4% vs 40.4%; p = 0.0087), a longer median hospital stay (12 days; interquartile range [IQR, 8–19 days] vs 10 days [IQR, 7–17 days]; p = 0.0007), and unplanned readmission (17.1% vs 12.9%; p = 0.0266). Black patients had a similar mortality rate to that of White patients and were less frequently discharged to home (67.6% vs 73.0%; p = 0.0315). Differences in morbidity between Black patients and White patients persisted after controlling for potentially confounding variables. Hispanic patients had lower mortality than White patients (6.3% vs 13.1%; p = 0.0130) and a longer hospital stay (12 days [IQR, 8–18 days] vs 10 days [IQR, 7–17 days]; p = 0.0313). Outcomes did not differ between Asian patients and White patients.

Conclusions

This study demonstrated significant disparities for Black patients undergoing surgery for MBO. Understanding and addressing what drives these differences, including systemic inequalities such as access to care and racial biases, is essential to the achievement of more equitable, higher-quality patient care.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Cohen JT, Miner TJ. Patient selection in palliative surgery: defining value. J Surg Oncol. 2019;120:35–44. https://doi.org/10.1002/jso.25512.

    Article  PubMed  Google Scholar 

  2. Paul Olson TJ, Pinkerton C, Brasel KJ, Schwarze ML. Palliative surgery for malignant bowel obstruction from carcinomatosis: a systematic review. JAMA Surg. 2014;149:383–92. https://doi.org/10.1001/jamasurg.2013.4059.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Krouse RS. Malignant bowel obstruction. J Surg Oncol. 2019;120:74–7. https://doi.org/10.1002/jso.25451.

    Article  PubMed  Google Scholar 

  4. Alese OB, Kim S, Chen Z, Owonikoko TK, El-Rayes BF. Management patterns and predictors of mortality among US patients with cancer hospitalized for malignant bowel obstruction. Cancer. 2015;121:1772–8. https://doi.org/10.1002/cncr.29297.

    Article  PubMed  Google Scholar 

  5. Roses RE, Folkert IW, Krouse RS. Malignant bowel obstruction: reappraising the value of surgery. Surg Oncol Clin North Am. 2018;27:705–15. https://doi.org/10.1016/j.soc.2018.05.010.

    Article  Google Scholar 

  6. Bateni SB, Bold RJ, Meyers FJ, Canter DJ, Canter RJ. Comparison of common risk stratification indices to predict outcomes among stage IV cancer patients with bowel obstruction undergoing surgery. J Surg Oncol. 2018;117:479–87. https://doi.org/10.1002/jso.24866.

    Article  PubMed  Google Scholar 

  7. Foster D, Shaikh MF, Gleeson E, Babcock BD, Ringold D, Bowne WB. Palliative surgery for advanced cancer: identifying evidence-based criteria for patient selection: case report and review of literature. J Palliat Med. 2016;19:22–9. https://doi.org/10.1089/jpm.2015.0146.

    Article  PubMed  Google Scholar 

  8. Ingersoll LT, Alexander SC, Priest J, et al. Racial/ethnic differences in prognosis communication during initial inpatient palliative care consultations among people with advanced cancer. Patient Educ Couns. 2019;102:1098–103. https://doi.org/10.1016/j.pec.2019.01.002.

    Article  PubMed  Google Scholar 

  9. Abbas A, Madison Hyer J, Pawlik TM. Race/ethnicity and county-level social vulnerability impact hospice utilization among patients undergoing cancer surgery. Ann Surg Oncol. 2021;28:1918–26. https://doi.org/10.1245/s10434-020-09227-6.

    Article  PubMed  Google Scholar 

  10. Jones RC, Creutzfeldt CJ, Cox CE, et al. Racial and ethnic differences in health care utilization following severe acute brain injury in the United States. J Intensive Care Med. Published online 10 September 2020:885066620945911. https://doi.org/10.1177/0885066620945911.

  11. Mehanna EK, Catalano PJ, Cagney DN, et al. Hospice utilization in elderly patients with brain metastases. J Natl Cancer Inst. 2020;112:1251–8. https://doi.org/10.1093/jnci/djaa036.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Paredes AZ, Hyer JM, Palmer E, Lustberg MB, Pawlik TM. Racial/ethnic disparities in hospice utilization among Medicare beneficiaries dying from pancreatic cancer. J Gastrointest Surg. 2021;25:155–61. https://doi.org/10.1007/s11605-020-04568-9.

    Article  PubMed  Google Scholar 

  13. Cohen LL. Racial/ethnic disparities in hospice care: a systematic review. J Palliat Med. 2008;11:763–8. https://doi.org/10.1089/jpm.2007.0216.

    Article  PubMed  Google Scholar 

  14. Kwak J, Haley WE, Chiriboga DA. Racial differences in hospice use and in-hospital death among Medicare and Medicaid dual-eligible nursing home residents. Gerontologist. 2008;48:32–41. https://doi.org/10.1093/geront/48.1.32.

    Article  PubMed  Google Scholar 

  15. Orlovic M, Smith K, Mossialos E. Racial and ethnic differences in end-of-life care in the United States: evidence from the Health and Retirement Study (HRS). SSM Popul Health. 2019;7:100331. https://doi.org/10.1016/j.ssmph.2018.100331.

    Article  PubMed  Google Scholar 

  16. Morris AM, Rhoads KF, Stain SC, Birkmeyer JD. Understanding racial disparities in cancer treatment and outcomes. J Am Coll Surg. 2010;211:105–13. https://doi.org/10.1016/j.jamcollsurg.2010.02.051.

    Article  PubMed  Google Scholar 

  17. Bateni SB, Gingrich AA, Kirane AR, et al. Chemotherapy after diagnosis of malignant bowel obstruction is associated with superior survival for Medicare patients with advanced malignancy. Ann Surg Oncol. Published online 7 April 2021. https://doi.org/10.1245/s10434-021-09831-0.

  18. Makar GS, Makar M, Obinero C, Davis W, Gaughan JP, Kwiatt M. Refusal of cancer-directed surgery in patients with colon cancer: risk factors of refusal and survival data. Ann Surg Oncol. 2021;28:606–16. https://doi.org/10.1245/s10434-020-08783-1.

    Article  PubMed  Google Scholar 

  19. Henley SJ, Ward EM, Scott S, et al. Annual report to the nation on the status of cancer, part I: national cancer statistics. Cancer. 2020;126:2225–49. https://doi.org/10.1002/cncr.32802.

    Article  PubMed  Google Scholar 

  20. Jemal A, Ward EM, Johnson CJ, et al. Annual report to the nation on the status of cancer, 1975–2014, featuring survival. J Natl Cancer Inst. 2017. https://doi.org/10.1093/jnci/djx030.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Azap RA, Diaz A, Hyer JM, et al. Impact of race/ethnicity and county-level vulnerability on receipt of surgery among older Medicare beneficiaries with the diagnosis of early pancreatic cancer. Ann Surg Oncol. Published online 12 April 2021. https://doi.org/10.1245/s10434-021-09911-1.

  22. Haider AH, Scott VK, Rehman KA, et al. Racial disparities in surgical care and outcomes in the United States: a comprehensive review of patient, provider, and systemic factors. J Am Coll Surg. 2013;216:482-92.e12. https://doi.org/10.1016/j.jamcollsurg.2012.11.014.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Breslin TM, Morris AM, Gu N, et al. Hospital factors and racial disparities in mortality after surgery for breast and colon cancer. J Clin Oncol Off J Am Soc Clin Oncol. 2009;27:3945–50. https://doi.org/10.1200/JCO.2008.20.8546.

    Article  Google Scholar 

  24. Dong J, Gu X, El-Serag HB, Thrift AP. Underuse of surgery accounts for racial disparities in esophageal cancer survival times: a matched cohort study. Clin Gastroenterol Hepatol Off Clin Pract J Am Gastroenterol Assoc. 2019;17:657-65.e13. https://doi.org/10.1016/j.cgh.2018.07.018.

    Article  Google Scholar 

  25. Wasif N, Etzioni D, Habermann EB, et al. Racial and socioeconomic differences in the use of high-volume commission on cancer-accredited hospitals for cancer surgery in the United States. Ann Surg Oncol. 2018;25:1116–25. https://doi.org/10.1245/s10434-018-6374-0.

    Article  PubMed  Google Scholar 

  26. Heard-Garris N, Onwuka E, Davis MM. Surgical mortality and race as a risk factor: a compass, not a destination. Pediatrics. 2018. https://doi.org/10.1542/peds.2017-3894.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Kaplan JB, Bennett T. Use of race and ethnicity in biomedical publication. JAMA. 2003;289:2709–16. https://doi.org/10.1001/jama.289.20.2709.

    Article  PubMed  Google Scholar 

  28. Dindo D, Demartines N, Clavien P-A. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–13. https://doi.org/10.1097/01.sla.0000133083.54934.ae.

    Article  PubMed  PubMed Central  Google Scholar 

  29. American College of Surgeons National Surgical Quality Improvement Program. User Guide for the 2019 ACS NSQIP Participant Use Data File (PUF). Published online October 2020. https://www.facs.org/quality-programs/acs-nsqip/participant-use.

  30. Song Y, Metzger DA, Bruce AN, et al. Surgical outcomes in patients with malignant small bowel obstruction: a national cohort study. Ann Surg. Published online 20 March 2020. doi:https://doi.org/10.1097/SLA.0000000000003890.

  31. Anthony T, Baron T, Mercadante S, et al. Report of the clinical protocol committee: development of randomized trials for malignant bowel obstruction. J Pain Symptom Manage. 2007;34(1 Suppl):S49-59. https://doi.org/10.1016/j.jpainsymman.2007.04.011.

    Article  PubMed  Google Scholar 

  32. Benchimol EI, Smeeth L, Guttmann A, et al. The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) statement. PLoS Med. 2015;12:e1001885. https://doi.org/10.1371/journal.pmed.1001885.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Haider AH, Bilimoria KY, Kibbe MR. A checklist to elevate the science of surgical database research. JAMA Surg. 2018;153:505–7. https://doi.org/10.1001/jamasurg.2018.0628.

    Article  PubMed  Google Scholar 

  34. Raval MV, Pawlik TM. Practical guide to surgical data sets: National Surgical Quality Improvement Program (NSQIP) and Pediatric NSQIP. JAMA Surg. 2018;153:764–5. https://doi.org/10.1001/jamasurg.2018.0486.

    Article  PubMed  Google Scholar 

  35. JMP®, version 15.1. SAS Institute Inc., Cary, NC, 1989–2019.

  36. Arsoniadis EG, Ho Y-Y, Melton GB, Madoff RD, Le C, Kwaan MR. African Americans and short-term outcomes after surgery for Crohn’s disease: an ACS-NSQIP analysis. J Crohns Colitis. 2017;11:468–73. https://doi.org/10.1093/ecco-jcc/jjw175.

    Article  PubMed  Google Scholar 

  37. Gupta R, Woo K, Yi JA. Epidemiology of end-stage kidney disease. Semin Vasc Surg. 2021;34:71–8. https://doi.org/10.1053/j.semvascsurg.2021.02.010.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Bress AP, Cohen JB, Anstey DE, et al. Inequities in hypertension control in the United States exposed and exacerbated by COVID-19 and the role of home blood pressure and virtual health care during and after the COVID-19 pandemic. J Am Heart Assoc. 2021;10:e020997. https://doi.org/10.1161/JAHA.121.020997.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  39. Jean RA, Chiu AS, O’Neill KM, Lin Z, Pei KY. The influence of sociodemographic factors on operative decision-making in small bowel obstruction. J Surg Res. 2018;227:137–44. https://doi.org/10.1016/j.jss.2018.02.029.

    Article  PubMed  Google Scholar 

  40. Vu JV, Gunaseelan V, Dimick JB, Englesbe MJ, Campbell DA, Telem DA. Mechanisms of age and race differences in receiving minimally invasive inguinal hernia repair. Surg Endosc. 2019;33:4032–7. https://doi.org/10.1007/s00464-019-06695-0.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Mustapha JA, Fisher BT, Rizzo JA, et al. Explaining racial disparities in amputation rates for the treatment of peripheral artery disease (PAD) using decomposition methods. J Racial Ethn Health Disparities. Published online 15 February 2017. https://doi.org/10.1007/s40615-016-0261-9.

  42. Guerra ME, Jean RA, Chiu AS, Johnson DC. The effect of sociodemographic factors on outcomes and time to discharge after bariatric operations. Am J Surg. 2020;219:571–7. https://doi.org/10.1016/j.amjsurg.2020.02.046.

    Article  PubMed  Google Scholar 

  43. Sanaiha Y, Bailey KL, Aguayo E, et al. Racial disparities in the incidence of pulmonary embolism after colectomy. Am Surg. 2018;84:1560–4.

    Article  Google Scholar 

  44. Sanford Z, Taylor H, Fiorentino A, et al. Racial disparities in surgical outcomes after spine surgery: an ACS-NSQIP analysis. Glob Spine J. 2019;9:583–90. https://doi.org/10.1177/2192568218811633.

    Article  Google Scholar 

  45. Lilley EJ, Bader AM, Cooper Z. A values-based conceptual framework for surgical appropriateness: an illustrative case report. Ann Palliat Med. 2015;4:54–7. https://doi.org/10.3978/j.issn.2224-5820.2015.05.01.

    Article  PubMed  Google Scholar 

  46. Gomes B, Calanzani N, Gysels M, Hall S, Higginson IJ. Heterogeneity and changes in preferences for dying at home: a systematic review. BMC Palliat Care. 2013;12:7. https://doi.org/10.1186/1472-684X-12-7.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Mpody C, Humphrey L, Kim S, Tobias JD, Nafiu OO. Racial differences in do-not-resuscitate orders among pediatric surgical patients in the United States. J Palliat Med. 2021;24:71–6. https://doi.org/10.1089/jpm.2020.0053.

    Article  PubMed  Google Scholar 

  48. Phadke A, Heidenreich PA. Differences and trends in DNR among California inpatients with heart failure. J Card Fail. 2016;22:312–5. https://doi.org/10.1016/j.cardfail.2015.12.005.

    Article  PubMed  Google Scholar 

  49. Mayeda DP, Ward KT. Methods for overcoming barriers in palliative care for ethnic/racial minorities: a systematic review. Palliat Support Care. 2019;17:697–706. https://doi.org/10.1017/S1478951519000403.

    Article  PubMed  Google Scholar 

  50. Barnato AE, Anthony DL, Skinner J, Gallagher PM, Fisher ES. Racial and ethnic differences in preferences for end-of-life treatment. J Gen Intern Med. 2009;24:695–701. https://doi.org/10.1007/s11606-009-0952-6.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Cagle JG, LaMantia MA, Williams SW, Pek J, Edwards LJ. Predictors of preference for hospice care among diverse older adults. Am J Hosp Palliat Med. 2016;33:574–84. https://doi.org/10.1177/1049909115593936.

    Article  Google Scholar 

  52. Hagiwara N, Elston Lafata J, Mezuk B, Vrana SR, Fetters MD. Detecting implicit racial bias in provider communication behaviors to reduce disparities in healthcare: challenges, solutions, and future directions for provider communication training. Patient Educ Couns. 2019;102:1738–43. https://doi.org/10.1016/j.pec.2019.04.023.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Barnato AE, Mohan D, Downs J, Bryce CL, Angus DC, Arnold RM. A randomized trial of the effect of patient race on physicians’ intensive care unit and life-sustaining treatment decisions for an acutely unstable elder with end-stage cancer. Crit Care Med. 2011;39:1663–9. https://doi.org/10.1097/CCM.0b013e3182186e98.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  54. Khorana AA, Tullio K, Elson P, et al. Time to initial cancer treatment in the United States and association with survival over time: an observational study. PloS One. 2019;14:e0213209. https://doi.org/10.1371/journal.pone.0213209.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  55. Ramzan AA, Behbakht K, Corr BR, Sheeder J, Guntupalli SR. Minority race predicts treatment by non-gynecologic oncologists in women with gynecologic cancer. Ann Surg Oncol. 2018;25:3685–91. https://doi.org/10.1245/s10434-018-6694-0.

    Article  PubMed  Google Scholar 

  56. Pollack LM, Olsen MA, Gehlert SJ, Chang S-H, Lowder JL. Racial/ethnic disparities/differences in hysterectomy route in women likely eligible for minimally invasive surgery. J Minim Invasive Gynecol. 2020;27:1167-77.e2. https://doi.org/10.1016/j.jmig.2019.09.003.

    Article  PubMed  Google Scholar 

  57. Cole AP, Nguyen D-D, Meirkhanov A, et al. Association of care at minority-serving vs non-minority-serving hospitals with use of palliative care among racial/ethnic minorities with metastatic cancer in the United States. JAMA Netw Open. 2019;2:e187633. https://doi.org/10.1001/jamanetworkopen.2018.7633.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Mehtsun WT, Figueroa JF, Zheng J, Orav EJ, Jha AK. Racial disparities in surgical mortality: the gap appears to have narrowed. Health Aff Proj Hope. 2017;36:1057–64. https://doi.org/10.1377/hlthaff.2017.0061.

    Article  Google Scholar 

  59. Penman-Aguilar A, Talih M, Huang D, Moonesinghe R, Bouye K, Beckles G. Measurement of health disparities, health inequities, and social determinants of health to support the advancement of health equity. J Public Health Manag Pract JPHMP. 2016;22(Suppl 1):S33-42. https://doi.org/10.1097/PHH.0000000000000373.

    Article  PubMed  Google Scholar 

  60. Diaz A, Hyer JM, Barmash E, Azap R, Paredes AZ, Pawlik TM. County-level social vulnerability is associated with worse surgical outcomes especially among minority patients. Ann Surg. 2020. Published ahead of print. doi:https://doi.org/10.1097/SLA.0000000000004691.

  61. Paro A, Dalmacy D, Madison Hyer J, Tsilimigras DI, Diaz A, Pawlik TM. Impact of residential racial integration on postoperative outcomes among Medicare beneficiaries undergoing resection for cancer. Ann Surg Oncol. Published online 24 April 2021. https://doi.org/10.1245/s10434-021-10034-w.

  62. Lai Y, Wang C, Civan JM, et al. Effects of cancer stage and treatment differences on racial disparities in survival from colon cancer: a United States population-based study. Gastroenterology. 2016;150:1135–46. https://doi.org/10.1053/j.gastro.2016.01.030.

    Article  PubMed  Google Scholar 

  63. Sineshaw HM, Ng K, Flanders WD, Brawley OW, Jemal A. Factors that contribute to differences in survival of black vs white patients with colorectal cancer. Gastroenterology. 2018;154:906-15.e7. https://doi.org/10.1053/j.gastro.2017.11.005.

    Article  PubMed  Google Scholar 

  64. Velasco-Mondragon E, Jimenez A, Palladino-Davis AG, Davis D, Escamilla-Cejudo JA. Hispanic health in the USA: a scoping review of the literature. Public Health Rev. 2016;37:31. https://doi.org/10.1186/s40985-016-0043-2.

    Article  PubMed  PubMed Central  Google Scholar 

  65. Ahmmad Z, Wen M, Li K. Self-rated health disparities among Asian Americans: mediating roles of education level and household income. J Immigr Minor Health. 2021;23:583–90. https://doi.org/10.1007/s10903-020-01051-0.

    Article  PubMed  Google Scholar 

  66. Medina HN, Callahan KE, Morris CR, Thompson CA, Siweya A, Pinheiro PS. Cancer mortality disparities among Asian American and native Hawaiian/Pacific Islander populations in California. Cancer Epidemiol Biomark Prev Publ Am Assoc Cancer Res Cosponsored Am Soc Prev Oncol. Published online 20 April 2021. https://doi.org/10.1158/1055-9965.EPI-20-1528.

  67. Lilley EJ, Scott JW, Goldberg JE, et al. Survival, healthcare utilization, and end-of-life care among older adults with malignancy-associated bowel obstruction: comparative study of surgery, venting gastrostomy, or medical management. Ann Surg. 2018;267:692–9. https://doi.org/10.1097/SLA.0000000000002164.

    Article  PubMed  Google Scholar 

Download references

Acknowledgment

We thank Dr. Steven Grambow, Ph.D. for providing his expertise and suggestions for the statistical analysis portion of this study.

Author information

Authors and Affiliations

  1. Duke University School of Medicine, Duke Health, Durham, NC, USA

    Caitlin L. Penny BS, Sean M. Tanino MS & Paul J. Mosca MD, PhD, MBA

  2. Department of Surgery, Duke Health, Durham, NC, USA

    Paul J. Mosca MD, PhD, MBA

  3. Duke Network Services, Duke Health, Durham, NC, USA

    Paul J. Mosca MD, PhD, MBA

Authors
  1. Caitlin L. Penny BS
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sean M. Tanino MS
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Paul J. Mosca MD, PhD, MBA
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Paul J. Mosca MD, PhD, MBA.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Penny, C.L., Tanino, S.M. & Mosca, P.J. Racial Disparities in Surgery for Malignant Bowel Obstruction. Ann Surg Oncol 29, 3122–3133 (2022). https://doi.org/10.1245/s10434-021-11161-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1245/s10434-021-11161-0

Search

Navigation