Background: Significant racial and socioeconomic disparities persist in the survival of

patients with select cancers in California. There are a limited number of studies that have

evaluated the association between National Comprehensive Cancer Network (NCCN)

guideline adherent care and survival across different cancer types. We aim to assess the

relationship between race/ethnicity, socioeconomic status (SES), insurance type and the

likelihood of receiving NCCN guideline adherent care and its association with cancer-specific

survival.

Objectives: To determine the relationship between NCCN guideline adherence and disease-specific survival across selected cancer types. Our secondary objective is to better understand the association of race/ethnicity, socioeconomic status, payer type, and disease characteristics with the receipt of NCCN guideline adherent care.

Methods: This was a retrospective population-based cohort study of patients with one of

eight different types of invasive cancer using the California Cancer Registry. A total of

543,198 patients were identified with invasive cancer between 2004-2017 (breast,

n=189,311; prostate, n=156,502; colon, n=80,102; rectal, n=30,118; liver, n=25,857; gastric,

n=22,066; ovary, n=22,551; and cervix, n=16,691). Adherence with NCCN guideline care was

defined by histology and stage-appropriate surgical procedures, radiation, and chemo- or

hormonal therapies. Multivariate logistic regression was used to evaluate the relationship

between the patient’s race/ethnicity, SES, insurance type, and NCCN guideline adherence.

Disease-specific survival analysis was performed using multivariate proportional hazards

model.

Results: A total of 543,198 patients were identified with invasive cancer from 2004 to 2017

(cases by disease: breast 189,311, prostate 156,502, colon 80,102, rectal 30,118, liver 25,857,

gastric 22,066, ovary 22,551, and cervix 16,691). Overall, less than half of patients (47.5%)

received guideline-adherent care and this proportion varied by disease type (30-80%). Non-

adherent treatment was associated with worse survival across all cancer types: breast (HR

1.28, 95%CI=1.23-1.33), prostate (HR 1.31, 95%CI=1.22-1.41), colon (HR 1.73, 95%CI=1.67

1.78), rectal (HR 1.52, 95%CI=1.41-1.63), liver (HR 2.52, 95%CI=2.42-2.63), ovary (HR 1.32,

95%CI=1.26-1.38), gastric (HR 2.38, 95%CI=2.28-2.49), and cervical cancer (HR 1.17,

95%CI=1.08-1.26). In multivariate models, Black patients were less likely to receive guideline

adherent care for breast (OR 0.88, 95% CI 0.84-0.92), prostate (OR 0.90, 95% CI 0.86-0.93),

colon (OR 0.86, 95% CI 0.80-0.92), and ovarian cancer (OR 0.71, 95% CI 0.62-0.82) compared

to White patients. Hispanic patients were less likely to receive guideline-adherent care for

breast (OR 0.91, 95%CI=0.88-0.93) and liver cancer (OR 0.86, 95%CI=0.80-0.91), compared to

White patients. Medicaid payer status was also associated with lower guideline

adherence for breast (OR 0.81, 95% CI 0.78-0.84), prostate (OR 0.91, 95% CI 0.86-0.97), colon (OR 0.70, 95% CI 0.65-0.75), rectal (OR 0.91, 95% CI 0.83-0.99), gastric (OR 0.69, 95% CI 0.63-0.75), and liver cancer (OR 0.66, 95% CI 0.61-0.72), compared to managed care insurance type. Patients in the lowest socioeconomic group were less likely to receive guideline adherent care across all cancer types compared to the highest SES group (breast OR 0.77, 95%CI 0.74-0.80; prostate OR 0.86, 95%CI 0.82-0.89; colon OR 0.50, 95%CI 0.46-0.53; rectal OR 0.79, 95%CI 0.72-0.86; liver OR 0.61, 95%CI 0.55-0.67; gastric OR 0.54, 95%CI 0.48-0.59; ovary OR 0.60, 95%CI 0.54-0.67; cervix OR 0.86, 95%CI 0.77-0.97).

Conclusion: Less than half of cancer patients received NCCN guideline adherent care and

non-adherence was associated with an increased disease-specific mortality. There was an

incremental relationship observed between SES and the likelihood of receiving guideline

adherent care. Individuals less likely to receive guideline adherent care also included patients

of Black or Hispanic race and those with Medicaid or Medicare insurance coverage.

ABSTRACT OF THE THESIS

Impact of Race and Ethnicity on Short-term Surgical Outcomes in Women Treated

for Cervical Cancer: American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), 2011-2014

By

Paula M. Gutierrez

Master of Science in Biomedical and Translational Science

University of California, Irvine, 2017

Professor Dr. Robert E. Bristow, Chair

Variations in access to U.S. healthcare have contributed to racial and ethnic disparities in cervical cancer survival and mortality patterns. Evaluation of postoperative complications after cervical cancer surgery in American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) hospitals’ remains limited. In this study, we investigate the association between race/ethnicity and 30-day morbidity in women undergoing cervical cancer surgery.

Using ACS-NSQIP database, 1248 patients undergoing surgery in 2011-2014 were identified. In this cohort, 70.6% were non-Hispanic White, 12.8% Black and 16.5% Hispanic. Compared to non-Hispanic White, these minority groups were more likely to have medical comorbidities. In adjusted multivariable models, the odds of any postoperative complication were 50% greater in Black compared to non-Hispanic White (p<0.05), including non-surgical complications (OR=1.55, p<0.05). Hispanic ethnicity was not a predictor of 30-day morbidity (OR=0.76; p>0.05).

While Black patients experienced greater non-surgical adverse outcomes, no disparity was observed for Hispanic patients. Findings suggest that to some extent access to ACS NSQIP hospitals can attenuate disparities in postoperative complications after cervical cancer surgery, but much more work is still required to eliminate racial/ethnic disparities.

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Introduction/Background: Hispanic subgroups are often grouped under the combined Hispanic global term, preventing us from identifying any differences or disparities within that group that might exist. As California currently has the largest collectively identified Hispanic population in the US at 39%, data maintained for California has an adequate sample for the study of subgroups within this population for differences in health and illness. This paper will examine cancer-related survival involving the eight major cancer sites: colon, rectum, stomach, liver, female breast, prostate, ovary, and cervix. This study aims to discern whether there are differences in cancer-related survival in the following Hispanic subgroups: Mexican, Puerto Rican, Cuban, Southern or Central American, and other Spanish/Hispanic origin.

Methods: Data was gathered from the California Cancer Registry (CCR) using 2004-2017 to conduct a retrospective longitudinal population-based cohort study. The following patient characteristics were obtained: race/ethnicity, age at diagnosis, year of diagnosis, gender, insurance type, socioeconomic status (SES), marital status, type of hospital where treatment was received, adherence to treatment status, tumor stage, and tumor grade. Cancer types included both male and female cancers: colon, rectum, stomach, liver, prostate, female breast, ovary, and cervix. A multivariate proportional hazards model was used to perform a cancer-specific survival analysis while controlling for numerous potential confounders. Non-Hispanic white (NHW) cases were used as the comparison group for each Hispanic subgroup. There were no comparisons between Hispanic subgroups themselves.

Results: Between 2004-2017, 420,671 cases of cancer were identified. Of these, 306,262 (72.8%) were NHW, 34,897 (8.3%) were Mexican, 647 (0.2%) were Puerto Rican, 698 (0.2%) were Cuban, 9,638 (2.3%) were South or Central American, and 68,528 (16.3%) were other Spanish/Hispanic origins. Compared to NHW cases, Mexican race/ethnicity was associated with better survival for colon (HR 0.89, 95% CI 0.84-0.96, p=0.0008) and liver cancer (HR 0.88, 95% CI 0.82-0.95, p=0.0006), but Mexican race/ethnicity was associated with worse survival for stomach cancer (HR 1.19, 95% CI 1.10-1.27, p<0.0001). South or Central American was associated with better survival for colon (HR 0.74, 95% CI 0.65-0.83, p<0.0001), liver (HR 0.69, 95% CI 0.60-0.80, p<0.0001), breast (HR 0.88, 95% CI 0.78-0.99, p=0.0303), and cervix (HR 0.70, 95% CI 0.58-0.85, p=0.0003). Most Hispanic subgroups had no difference in survival rates over a 5-year period compared to NHWs or were associated with better survival rates than NHWs. Only among Mexicans with stomach cancer were the survival rates worse than NHWs.

Conclusion: Compared to NHW cases, Mexicans were the only Hispanic subgroup associated with worse survival rates; this was found only among stomach cancer patients. For the rest of our results, Hispanic subgroups were associated with better or similar survival rates than NHWs. These results reinforce previous studies highlighting the Hispanic paradox. Hispanics have better cancer survival outcomes than NHWs despite health disparities such as lower SES and less healthcare access. Nonetheless, we do see worse survival, at least in one subgroup, which should encourage us to report Hispanics as disaggregate groups to identify differences when they exist. We also saw a large portion of unknown Hispanic data, which highlights the need for better practices in race/ethnic identification in data collection. Such practices will then enable us to develop targeted interventions and policies that will improve the health of this fast-growing ethnic population.

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