Blacks less likely to undergo sphincter-sparing surgery for rectal cancer

Blacks in the US are more likely than whites to undergo abdominoperineal resection for rectal cancer, a procedure that necessitates a permanent colostomy, physicians report in the February Archives of Surgery. At least part of the reason seems to be regional differences in delivering standard of care.

Dr. Arden M. Morris, at the University of Minnesota in Minneapolis, and colleagues analyzed data from the Surveillance Epidemiology and End Results (SEER) Cancer Incidence Database to compare racial variations in the treatment of rectal cancer.Among 3851 blacks and 44,010 whites diagnosed between 1988 and 1999, rectal cancer overall was diagnosed at younger age (64 versus 69 years, p < 0.001) and at more advanced stages (p < 0.001 for trend). Approximately 40% of patients were diagnosed with stage II or III cancer.Among those with stage II or III cancer, a sphincter-ablating procedure was performed for 37% of white patients and 43% of black patients. The difference remained significant after adjusting for age, gender, disease stage, geographic region, and year of diagnosis."I suspect a major issue here is access to care," and that "race is a proxy for socioeconomic status," Dr. Morris said in an interview with Reuters Health. However, the reasons why ethnicity is associated with surgical procedures are not straightforward, she noted. For example, an abdominoperineal resection is a lengthier procedure and costs more than does surgery that preserves normal bowel continuity."The SEER database is an excellent source of broad information, but it does not go very deep," Dr. Morris said. As a result, she and her associates were not able to control for such factors as insurance coverage, physician characteristics and type of hospital system.The authors were surprised to find that fewer than 50% of patients underwent radiation treatment, she said. Only 7% received neoadjuvant radiation, which is increasingly the standard of care because it leads to tumor downstaging prior to surgery and thus requires less extensive resection."It seems that all patients are underserved, and some patients are more underserved than other," Dr. Morris said.In an invited critique, Dr. Michael J. Stamos observes that 86% of the African American patients were treated at four of the nine SEER sites, compared with 44% of whites. "It is easy to see how geographic variation or perhaps even individual hospital variation within these geographic regions could easily account for a difference of 6% in the overall use of sphincter-sparing procedures between African American and white patients," writes Dr. Stamos, who is based in Orange, California."We as a surgical community must do a better job at disseminating training and advanced care algorithms to all of the surgeons in the United States," he writes.(Source: Arch Surg 2004;139:151-155,156: Reuters Health: Karla Gale: February 10, 2004: Oncolink)